Healthcare Provider Details

I. General information

NPI: 1972952729
Provider Name (Legal Business Name): JACKLYN SAMPSON PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2016
Last Update Date: 06/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 ALEXANDRIA PIKE
COLD SPRING KY
41076-2169
US

IV. Provider business mailing address

110 GREEN HILL DR
COVINGTON KY
41017-9431
US

V. Phone/Fax

Practice location:
  • Phone: 859-448-4210
  • Fax:
Mailing address:
  • Phone: 859-640-4990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License Number03135751
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: