Provider Demographics
NPI:1750729414
Name:SAM, MERRIL
Entity type:Individual
Prefix:
First Name:MERRIL
Middle Name:
Last Name:SAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:532 BROADHOLLOW RD
Mailing Address - Street 2:SUITE 137
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-3672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:532 BROADHOLLOW RD
Practice Address - Street 2:SUITE 137
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-3672
Practice Address - Country:US
Practice Address - Phone:516-249-7400
Practice Address - Fax:516-249-7432
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist