MEDICARE: DR. OMAR A SHADDAD PHARM. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	065047	NY

General Provider Information

NPI Number	:	1215407002
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OMAR A SHADDAD PHARM. D.

Provider Business Mailing Address
First Line	:	3332 71ST ST FL 1
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-1057
Country	:	US
Telephone Number	:	929-261-0024
Fax Number	:

Provider Business Practice Location Address
First Line	:	3332 71ST ST FL 1
Second Line	:
City	:	JACKSON HEIGHTS
State	:	NY
Zip	:	11372-1057
Country	:	US
Telephone Number	:	929-261-0024
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2018
Last Update Date	:	12/05/2018

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