MEDICARE: SAMER KOLEILAT RPH

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	PS30004	FL

General Provider Information

NPI Number	:	1962770099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMER KOLEILAT RPH

Provider Business Mailing Address
First Line	:	2500 E LAS OLAS BLVD
Second Line	:	APT 1009
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-1508
Country	:	US
Telephone Number	:	954-463-0613
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 N OCEAN BLVD
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-7115
Country	:	US
Telephone Number	:	954-564-8424
Fax Number	:

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

Provider Enumeration Date	:	12/04/2011
Last Update Date	:	12/04/2011

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