Healthcare Provider Details

I. General information

NPI: 1083756019
Provider Name (Legal Business Name): SAMUEL L WADDELL II RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 MEADE BR
SITKA KY
41255-9335
US

IV. Provider business mailing address

377 MEADE BR
SITKA KY
41255-9335
US

V. Phone/Fax

Practice location:
  • Phone: 606-369-6356
  • Fax:
Mailing address:
  • Phone: 606-369-6356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number011108
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License Number011108
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: