Provider Demographics
NPI:1235968348
Name:HENRY, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:HENRY
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 1:4420 OCOEE ST N
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-4833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4420 OCOEE ST N
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-4833
Practice Address - Country:US
Practice Address - Phone:423-472-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN48321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist