MEDICARE: SHADY ALY ISMAIL ELATTAR

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	PR5603	ME

General Provider Information

NPI Number	:	1356574941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHADY ALY ISMAIL ELATTAR

Provider Business Mailing Address
First Line	:	15 LEDGES CT
Second Line	:
City	:	LEWISTON
State	:	ME
Zip	:	04240-1851
Country	:	US
Telephone Number	:	207-423-9986
Fax Number	:

Provider Business Practice Location Address
First Line	:	62 W GRAY RD
Second Line	:
City	:	GRAY
State	:	ME
Zip	:	04039-9772
Country	:	US
Telephone Number	:	207-657-2333
Fax Number	:

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

Provider Enumeration Date	:	08/28/2009
Last Update Date	:	08/28/2009

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Directions to “ SHADY ALY ISMAIL ELATTAR ” Practice Location

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