Provider Demographics
NPI:1073053567
Name:ELSHEHADEH, ROA MAZEN (RPH)
Entity Type:Individual
Prefix:
First Name:ROA
Middle Name:MAZEN
Last Name:ELSHEHADEH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 E 48TH ST
Mailing Address - Street 2:APT 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-3705
Mailing Address - Country:US
Mailing Address - Phone:347-404-3611
Mailing Address - Fax:
Practice Address - Street 1:1717 E 48TH ST
Practice Address - Street 2:APT 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3705
Practice Address - Country:US
Practice Address - Phone:347-404-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062588183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist