Provider Demographics
NPI:1215407002
Name:SHADDAD, OMAR A (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:A
Last Name:SHADDAD
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 71ST ST FL 1
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-1057
Mailing Address - Country:US
Mailing Address - Phone:929-261-0024
Mailing Address - Fax:
Practice Address - Street 1:3332 71ST ST FL 1
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-1057
Practice Address - Country:US
Practice Address - Phone:929-261-0024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065047183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist