Provider Demographics
NPI:1487033379
Name:ASSALI, OMAR
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:
Last Name:ASSALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16850 HAZELWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-7913
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:450 E CYPRESS AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-6115
Practice Address - Country:US
Practice Address - Phone:909-793-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-25
Last Update Date:2015-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45465183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist