Healthcare Provider Details

I. General information

NPI: 1497964910
Provider Name (Legal Business Name): SAMUEL MICHAEL COSMELLO D.O. RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 SPRING ST
GREENWOOD SC
29646-3860
US

IV. Provider business mailing address

109 REEDY COVE CT
GREENWOOD SC
29649-7935
US

V. Phone/Fax

Practice location:
  • Phone: 239-292-9699
  • Fax:
Mailing address:
  • Phone: 239-292-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS34309
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2013-00495
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberDO36671
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: