Provider Demographics
NPI:1164911640
Name:GERGIS, MAGED
Entity Type:Individual
Prefix:
First Name:MAGED
Middle Name:
Last Name:GERGIS
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 1:204 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022-2305
Mailing Address - Country:US
Mailing Address - Phone:602-375-0093
Mailing Address - Fax:602-375-0838
Practice Address - Street 1:204 E BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-2305
Practice Address - Country:US
Practice Address - Phone:602-375-0093
Practice Address - Fax:602-375-0838
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS023207183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist