Provider Demographics
NPI:1578020962
Name:TAKLA, FADY
Entity Type:Individual
Prefix:
First Name:FADY
Middle Name:
Last Name:TAKLA
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 1:4401 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2731
Mailing Address - Country:US
Mailing Address - Phone:323-231-9307
Mailing Address - Fax:
Practice Address - Street 1:4401 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2731
Practice Address - Country:US
Practice Address - Phone:323-231-9307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76385183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist