Provider Demographics
NPI:1972842441
Name:BOBO, SAMUEL THOMAS (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:THOMAS
Last Name:BOBO
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 N MOODY DR
Mailing Address - Street 2:
Mailing Address - City:RAY CITY
Mailing Address - State:GA
Mailing Address - Zip Code:31645-3743
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2815 N ASHLEY ST
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1806
Practice Address - Country:US
Practice Address - Phone:229-253-9069
Practice Address - Fax:229-253-9621
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA026943183500000X
SC13231183500000X
MSE-010518183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist