Healthcare Provider Details

I. General information

NPI: 1780996819
Provider Name (Legal Business Name): EJAZ HASAN RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2010
Last Update Date: 05/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 TIDEWATER DR
NORFOLK VA
23509-1436
US

IV. Provider business mailing address

515 N MAIN ST
SUFFOLK VA
23434-4426
US

V. Phone/Fax

Practice location:
  • Phone: 757-623-2706
  • Fax: 757-623-5209
Mailing address:
  • Phone: 757-539-9992
  • Fax: 757-539-0810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202209206
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: