Healthcare Provider Details

I. General information

NPI: 1255246344
Provider Name (Legal Business Name): SAMANTHA FAVAZZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 ROUTE 9 N
FREEHOLD NJ
07728-8503
US

IV. Provider business mailing address

3333 ROUTE 9 N
FREEHOLD NJ
07728-8503
US

V. Phone/Fax

Practice location:
  • Phone: 732-308-3627
  • Fax: 732-308-9519
Mailing address:
  • Phone: 732-308-3627
  • Fax: 732-308-9519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03165900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: