Healthcare Provider Details

I. General information

NPI: 1033582143
Provider Name (Legal Business Name): SHADI HADDADIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2015
Last Update Date: 11/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 VICTORIA AVE
PORT HUENEME CA
93041-2141
US

IV. Provider business mailing address

1030 QUAIL RUN WAY
OXNARD CA
93036-6280
US

V. Phone/Fax

Practice location:
  • Phone: 805-985-2326
  • Fax:
Mailing address:
  • Phone: 312-890-9027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number74040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: