Provider Demographics
NPI:1801064779
Name:WETHERILL, SAMUEL ROGERS IV (BS PHARMACY)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:ROGERS
Last Name:WETHERILL
Suffix:IV
Gender:M
Credentials:BS PHARMACY
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3931 KIRKWOOD HWY
Mailing Address - Street 2:7221ST MSU
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-5119
Mailing Address - Country:US
Mailing Address - Phone:410-920-4494
Mailing Address - Fax:
Practice Address - Street 1:3931 KIRKWOOD HWY
Practice Address - Street 2:7221ST MSU
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5119
Practice Address - Country:US
Practice Address - Phone:410-920-4494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE2848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DENO NUMBEROtherMILITARY TRICARE