Provider Demographics
NPI:1477019032
Name:FARESS, SHAFA
Entity Type:Individual
Prefix:
First Name:SHAFA
Middle Name:
Last Name:FARESS
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 1:2181 SPRINGFIELD AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:VAUXHALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07088-1233
Mailing Address - Country:US
Mailing Address - Phone:908-688-4849
Mailing Address - Fax:
Practice Address - Street 1:2181 SPRINGFIELD AVE UNIT B
Practice Address - Street 2:
Practice Address - City:VAUXHALL
Practice Address - State:NJ
Practice Address - Zip Code:07088-1233
Practice Address - Country:US
Practice Address - Phone:908-688-4849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
28RI031353003336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy