Healthcare Provider Details

I. General information

NPI: 1023522802
Provider Name (Legal Business Name): FADY M SAMAAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2017
Last Update Date: 09/05/2020
Certification Date: 09/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8044 LIMONITE AVE
RIVERSIDE CA
92509-6107
US

IV. Provider business mailing address

PO BOX 4098
TUSTIN CA
92781-4098
US

V. Phone/Fax

Practice location:
  • Phone: 951-685-0139
  • Fax:
Mailing address:
  • Phone: 949-396-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336C0004X
TaxonomyCompounding Pharmacy
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number77968
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: