Provider Demographics
NPI:1902323090
Name:BASIL, SAMUEL TED (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:TED
Last Name:BASIL
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 MEADOW BROOK RD
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:MS
Mailing Address - Zip Code:38652-8560
Mailing Address - Country:US
Mailing Address - Phone:662-266-7761
Mailing Address - Fax:
Practice Address - Street 1:1776 MCCULLOUGH BLVD
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-7101
Practice Address - Country:US
Practice Address - Phone:662-620-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-010537183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist