Provider Demographics
NPI:1194382036
Name:YASSA, FADY SAMAH SAMY
Entity Type:Individual
Prefix:
First Name:FADY
Middle Name:SAMAH SAMY
Last Name:YASSA
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 1:4204 PALM BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33905-3413
Mailing Address - Country:US
Mailing Address - Phone:239-694-2114
Mailing Address - Fax:
Practice Address - Street 1:4204 PALM BEACH BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-3413
Practice Address - Country:US
Practice Address - Phone:239-694-2114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-27
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54714183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist