Provider Demographics
NPI:1982936134
Name:MARDINI, SAMUEL G (RPH)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:G
Last Name:MARDINI
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 1:1610 NW LUOISIANA AVE
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-1711
Mailing Address - Country:US
Mailing Address - Phone:360-740-1876
Mailing Address - Fax:
Practice Address - Street 1:1610 LUOISIANA AVE NW
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-1711
Practice Address - Country:US
Practice Address - Phone:360-740-1876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-12
Last Update Date:2010-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60002564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist