Healthcare Provider Details

I. General information

NPI: 1548935703
Provider Name (Legal Business Name): ROBERT STEVEN SAMPLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 08/10/2021
Certification Date: 08/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1843 JOHNSON AVE NW
CEDAR RAPIDS IA
52405-4752
US

IV. Provider business mailing address

306 W POST RD SW
CEDAR RAPIDS IA
52404-1133
US

V. Phone/Fax

Practice location:
  • Phone: 319-365-5343
  • Fax:
Mailing address:
  • Phone: 319-249-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number13900
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: