Provider Demographics
NPI:1720758956
Name:POURNEZHAD, SAM (PHAMD)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:
Last Name:POURNEZHAD
Suffix:
Gender:M
Credentials:PHAMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11395 VEDRINES DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-7900
Mailing Address - Country:US
Mailing Address - Phone:770-617-7134
Mailing Address - Fax:
Practice Address - Street 1:11395 VEDRINES DR
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30022-7900
Practice Address - Country:US
Practice Address - Phone:770-617-7134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-18
Last Update Date:2021-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH033129183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist