Healthcare Provider Details

I. General information

NPI: 1790151736
Provider Name (Legal Business Name): SAMANTHA MOK PHAMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2015
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number72508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: