MEDICARE: FAGA SAMDUMU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	56081	TX

General Provider Information

NPI Number	:	1144679994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAGA SAMDUMU

Provider Business Mailing Address
First Line	:	203 E PECAN ST UNIT B
Second Line	:
City	:	HUTTO
State	:	TX
Zip	:	78634-3368
Country	:	US
Telephone Number	:	512-508-3369
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 INDEPENDENCE
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39710-5300
Country	:	US
Telephone Number	:	662-434-2168
Fax Number	:	662-434-2295

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2016
Last Update Date	:	06/11/2016

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