MEDICARE: SAMSON ASHUR SANDO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	TCH198364	CA

General Provider Information

NPI Number	:	1871313445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMSON ASHUR SANDO

Provider Business Mailing Address
First Line	:	3 BELLA DONACI
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92532-0114
Country	:	US
Telephone Number	:	702-722-8772
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 BELLA DONACI
Second Line	:
City	:	LAKE ELSINORE
State	:	CA
Zip	:	92532-0114
Country	:	US
Telephone Number	:	702-722-8772
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2024
Last Update Date	:	10/16/2024

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