Provider Demographics
NPI:1619578994
Name:BORN, SAMUEL DWAIN
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DWAIN
Last Name:BORN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1418
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TX
Mailing Address - Zip Code:75633-7418
Mailing Address - Country:US
Mailing Address - Phone:903-284-1083
Mailing Address - Fax:
Practice Address - Street 1:4609 NW LOOP # 436
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TX
Practice Address - Zip Code:75633-2205
Practice Address - Country:US
Practice Address - Phone:903-693-6502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29495183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty