Provider Demographics
NPI:1164276689
Name:TADROS, IHAB WAGDI AMIN
Entity Type:Individual
Prefix:
First Name:IHAB WAGDI AMIN
Middle Name:
Last Name:TADROS
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 1:11619 ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ISLAND CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97850-8459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11619 ISLAND AVE
Practice Address - Street 2:
Practice Address - City:ISLAND CITY
Practice Address - State:OR
Practice Address - Zip Code:97850-8459
Practice Address - Country:US
Practice Address - Phone:541-963-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0020006183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist