Provider Demographics
NPI:1942590070
Name:SELF, SAMUEL L JR (RPH)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:L
Last Name:SELF
Suffix:JR
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5492 MAGNOLIA TRACE
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35244
Mailing Address - Country:US
Mailing Address - Phone:205-982-7353
Mailing Address - Fax:
Practice Address - Street 1:5492 MAGNOLIA TRCE
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35244-4533
Practice Address - Country:US
Practice Address - Phone:205-982-5735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-11
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL11556OtherALABAMA STATE BOARD OF PHARMACY