MEDICARE: BEENA SAMPUGNARO

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	183500000X	Pharmacist	5302033667	MI

General Provider Information

NPI Number	:	1164707006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEENA SAMPUGNARO

Provider Business Mailing Address
First Line	:	23137 GREENCREST ST
Second Line	:
City	:	SAINT CLAIR SHORES
State	:	MI
Zip	:	48080-2522
Country	:	US
Telephone Number	:	586-201-4008
Fax Number	:

Provider Business Practice Location Address
First Line	:	1045 S GRATIOT AVE
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48036-3501
Country	:	US
Telephone Number	:	586-954-4905
Fax Number	:

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

Provider Enumeration Date	:	10/11/2011
Last Update Date	:	10/14/2011

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