Provider Demographics
NPI:1912175928
Name:JAYASURIYA, SAMANTHA DAWN
Entity Type:Individual
Prefix:MS
First Name:SAMANTHA
Middle Name:DAWN
Last Name:JAYASURIYA
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 1:4785 WEATHERHILL DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-1998
Mailing Address - Country:US
Mailing Address - Phone:201-937-9472
Mailing Address - Fax:
Practice Address - Street 1:4365 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5113
Practice Address - Country:US
Practice Address - Phone:302-995-2291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA10002904183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist