Provider Demographics
NPI:1770915464
Name:VANG, SAMUEL (RPH)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:VANG
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 MEMORIAL DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-3923
Mailing Address - Country:US
Mailing Address - Phone:920-793-7380
Mailing Address - Fax:920-793-7381
Practice Address - Street 1:5300 MEMORIAL DR
Practice Address - Street 2:SUITE 103
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3923
Practice Address - Country:US
Practice Address - Phone:920-793-7380
Practice Address - Fax:920-793-7381
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13748-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist