Provider Demographics
NPI:1144679994
Name:SAMDUMU, FAGA
Entity type:Individual
Prefix:
First Name:FAGA
Middle Name:
Last Name:SAMDUMU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:FAGA
Other - Middle Name:
Other - Last Name:SAMDUMU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:203 E PECAN ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-3368
Mailing Address - Country:US
Mailing Address - Phone:512-508-3369
Mailing Address - Fax:
Practice Address - Street 1:201 INDEPENDENCE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39710-5300
Practice Address - Country:US
Practice Address - Phone:662-434-2168
Practice Address - Fax:662-434-2295
Is Sole Proprietor?:No
Enumeration Date:2016-06-11
Last Update Date:2016-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX560811835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist