Healthcare Provider Details

I. General information

NPI: 1619209202
Provider Name (Legal Business Name): SAM ENBAWE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 02/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 WASHINGTON AVENUE EXT
ALBANY NY
12205-5612
US

IV. Provider business mailing address

5 JANET LN
ALBANY NY
12203-4207
US

V. Phone/Fax

Practice location:
  • Phone: 518-869-4697
  • Fax: 518-869-4699
Mailing address:
  • Phone: 518-928-7602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number053712
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: