Provider Demographics
NPI:1558908319
Name:ABDELFATTAH, OSSAMA
Entity Type:Individual
Prefix:
First Name:OSSAMA
Middle Name:
Last Name:ABDELFATTAH
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 1:12057 FIREKAT CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2073
Mailing Address - Country:US
Mailing Address - Phone:260-804-8764
Mailing Address - Fax:
Practice Address - Street 1:1890 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2502
Practice Address - Country:US
Practice Address - Phone:419-782-8079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-28
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03438838183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist