Provider Demographics
NPI:1124300728
Name:SAM, KERRY L (PHARMD)
Entity type:Individual
Prefix:MS
First Name:KERRY
Middle Name:L
Last Name:SAM
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SUMMER ST STE 365
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-1216
Mailing Address - Country:US
Mailing Address - Phone:508-363-6602
Mailing Address - Fax:
Practice Address - Street 1:123 SUMMER ST STE 365
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-363-6602
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC21465183500000X
MAPH27554183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist