Healthcare Provider Details

I. General information

NPI: 1144679994
Provider Name (Legal Business Name): FAGA SAMDUMU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: FAGA SAMDUMU PHARM D

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

201 INDEPENDENCE
COLUMBUS MS
39710-5300
US

IV. Provider business mailing address

203 E PECAN ST UNIT B
HUTTO TX
78634-3368
US

V. Phone/Fax

Practice location:
  • Phone: 662-434-2168
  • Fax: 662-434-2295
Mailing address:
  • Phone: 512-508-3369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number56081
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: