Provider Demographics
NPI:1073211876
Name:ELNAGGAR, ELMOTASEMBELLAH
Entity Type:Individual
Prefix:
First Name:ELMOTASEMBELLAH
Middle Name:
Last Name:ELNAGGAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13100 BROOK MIST LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-4407
Mailing Address - Country:US
Mailing Address - Phone:724-234-9943
Mailing Address - Fax:
Practice Address - Street 1:13031 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2050
Practice Address - Country:US
Practice Address - Phone:703-378-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202219897183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist