Provider Demographics
NPI:1184322679
Name:AGBAN, SAMAR GAMAL (RPH)
Entity type:Individual
Prefix:
First Name:SAMAR
Middle Name:GAMAL
Last Name:AGBAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:SAMAR
Other - Middle Name:GAMAL
Other - Last Name:AGBAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:18 DARNELL LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-1951
Mailing Address - Country:US
Mailing Address - Phone:347-445-3340
Mailing Address - Fax:
Practice Address - Street 1:520 CONVERY BLVD
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3021
Practice Address - Country:US
Practice Address - Phone:732-826-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-23
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02495800183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ28RI04295800OtherNABP