Provider Demographics
NPI:1770764664
Name:SAMUEL, SHEEBA GEORGE
Entity type:Individual
Prefix:MS
First Name:SHEEBA
Middle Name:GEORGE
Last Name:SAMUEL
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 1:27 BEATRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SYOSSET
Mailing Address - State:NY
Mailing Address - Zip Code:11791-4006
Mailing Address - Country:US
Mailing Address - Phone:917-805-5812
Mailing Address - Fax:
Practice Address - Street 1:346 ROUTE 25A STE 102
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-8425
Practice Address - Country:US
Practice Address - Phone:631-744-4300
Practice Address - Fax:631-744-3893
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00721884Medicaid