Healthcare Provider Details

I. General information

NPI: 1962323436
Provider Name (Legal Business Name): GHAITH BALLICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5502 E FOWLER AVE
TEMPLE TERRACE FL
33617-2226
US

IV. Provider business mailing address

12801 REAL MADRID LN
TAMPA FL
33617-1345
US

V. Phone/Fax

Practice location:
  • Phone: 813-984-1560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPSI44991
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: