Healthcare Provider Details

I. General information

NPI: 1316225162
Provider Name (Legal Business Name): IHAB ELSEWISY RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2011
Last Update Date: 07/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 SPRING ARBOR RD RITE AID #4539
JACKSON MI
49203-2701
US

IV. Provider business mailing address

2971 PHEASANT RUN DR #J
JACKSON MI
49202-1347
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-6630
  • Fax: 517-789-8439
Mailing address:
  • Phone: 201-850-7640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302036744
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: