Provider Demographics
NPI:1083360671
Name:FAKIH, HASSAN
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:FAKIH
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 1:19120 OAKMONT SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-3529
Mailing Address - Country:US
Mailing Address - Phone:131-382-8279
Mailing Address - Fax:
Practice Address - Street 1:19120 OAKMONT SOUTH DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-3529
Practice Address - Country:US
Practice Address - Phone:131-382-8279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist