Provider Demographics
NPI:1376128256
Name:HADDAD, MAISA (RPH)
Entity Type:Individual
Prefix:
First Name:MAISA
Middle Name:
Last Name:HADDAD
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30427 MONTRACHET ST
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-7213
Mailing Address - Country:US
Mailing Address - Phone:734-233-7466
Mailing Address - Fax:
Practice Address - Street 1:30427 MONTRACHET ST
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-7213
Practice Address - Country:US
Practice Address - Phone:734-233-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031556183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist