Provider Demographics
NPI:1164821757
Name:LEE, SAMANTHA TANG
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TANG
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3021 STATE ROAD 590 APT 115
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-2549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4450 PARK ST N
Practice Address - Street 2:PHARMACY
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-4020
Practice Address - Country:US
Practice Address - Phone:727-541-3930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-19
Last Update Date:2014-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS52489183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist