Provider Demographics
NPI:1831733294
Name:SAMRA, FREDERICK BLABAGNO (PHARMD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:BLABAGNO
Last Name:SAMRA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79795 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-4756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:79795 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-4756
Practice Address - Country:US
Practice Address - Phone:760-775-0363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPHA.0022894183500000X
NV20239183500000X
CA81761183500000X, 1835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist