Provider Demographics
NPI:1902406002
Name:SAMUEL, RENCY
Entity Type:Individual
Prefix:
First Name:RENCY
Middle Name:
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W INTERSTATE 20
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-3929
Mailing Address - Country:US
Mailing Address - Phone:972-988-1366
Mailing Address - Fax:972-988-6641
Practice Address - Street 1:2525 W INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-3929
Practice Address - Country:US
Practice Address - Phone:972-988-1366
Practice Address - Fax:972-988-6641
Is Sole Proprietor?:No
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX417481835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist