Healthcare Provider Details

I. General information

NPI: 1497632525
Provider Name (Legal Business Name): SAMANTHA RENEE MOGG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 W CEDAR AVE
GLADWIN MI
48624
US

IV. Provider business mailing address

307 W CEDAR AVE
GLADWIN MI
48624-2065
US

V. Phone/Fax

Practice location:
  • Phone: 989-709-5288
  • Fax: 989-709-5313
Mailing address:
  • Phone: 989-709-5288
  • Fax: 989-709-5313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: