Provider Demographics
NPI:1912485376
Name:BAGNOLA, SAMANTHA (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:BAGNOLA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:
Other - Last Name:OTTO-MEYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:121 W CHESTNUT ST APT 807
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60610-3148
Mailing Address - Country:US
Mailing Address - Phone:330-936-3459
Mailing Address - Fax:
Practice Address - Street 1:1330 CLARK ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-9614
Practice Address - Country:US
Practice Address - Phone:740-421-9530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-29
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.301213183500000X
OH03442826183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist