Provider Demographics
NPI:1649634239
Name:SAMUELSON, JEFFREY WILLIAM WYLIE (CPHT)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:WILLIAM WYLIE
Last Name:SAMUELSON
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:W
Other - Last Name:SAMUELSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPHT
Mailing Address - Street 1:1423 BROADWAY STE 122
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2054
Mailing Address - Country:US
Mailing Address - Phone:510-984-4916
Mailing Address - Fax:510-989-9089
Practice Address - Street 1:2175 MARKET STREET
Practice Address - Street 2:UNIT 122
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-1477
Practice Address - Country:US
Practice Address - Phone:628-895-9508
Practice Address - Fax:628-895-9509
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA134195183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician