Provider Demographics
NPI:1275167439
Name:AL BAZZAZ, MAYASAH ANAS SEDEEQ
Entity Type:Individual
Prefix:
First Name:MAYASAH
Middle Name:ANAS SEDEEQ
Last Name:AL BAZZAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15122 NW FIG LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-6986
Mailing Address - Country:US
Mailing Address - Phone:971-340-6940
Mailing Address - Fax:
Practice Address - Street 1:15122 NW FIG LN
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-6986
Practice Address - Country:US
Practice Address - Phone:971-340-6940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist