Provider Demographics
NPI:1942403340
Name:SAMSON, TRACY ELIZABETH (RPH)
Entity Type:Individual
Prefix:MRS
First Name:TRACY
Middle Name:ELIZABETH
Last Name:SAMSON
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15681 84TH PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55311-1560
Mailing Address - Country:US
Mailing Address - Phone:763-420-7861
Mailing Address - Fax:
Practice Address - Street 1:24 3RD ST NE
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:MN
Practice Address - Zip Code:55369-1212
Practice Address - Country:US
Practice Address - Phone:763-493-5242
Practice Address - Fax:763-493-2621
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116412-3183500000X
ND3861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2418526OtherNABP