Provider Demographics
NPI:1316225162
Name:ELSEWISY, IHAB (RPH)
Entity Type:Individual
Prefix:MR
First Name:IHAB
Middle Name:
Last Name:ELSEWISY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2971 PHEASANT RUN DR
Mailing Address - Street 2:#J
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1347
Mailing Address - Country:US
Mailing Address - Phone:201-850-7640
Mailing Address - Fax:
Practice Address - Street 1:1733 SPRING ARBOR RD
Practice Address - Street 2:RITE AID #4539
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-2701
Practice Address - Country:US
Practice Address - Phone:517-789-6630
Practice Address - Fax:517-789-8439
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-28
Last Update Date:2011-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036744183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist