Healthcare Provider Details

I. General information

NPI: 1285591891
Provider Name (Legal Business Name): SAM KETANEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2026
Last Update Date: 01/06/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 US-7 N
MILTON VT
05468
US

IV. Provider business mailing address

259 US-7 N
MILTON VT
05468
US

V. Phone/Fax

Practice location:
  • Phone: 802-893-0554
  • Fax:
Mailing address:
  • Phone: 802-893-0554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number033.0135754
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: