Provider Demographics
NPI:1598401812
Name:ELHUSSIEN, EBTISAM (RPH)
Entity Type:Individual
Prefix:
First Name:EBTISAM
Middle Name:
Last Name:ELHUSSIEN
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 1:22 KATIE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2857
Mailing Address - Country:US
Mailing Address - Phone:203-927-6382
Mailing Address - Fax:
Practice Address - Street 1:66 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3304
Practice Address - Country:US
Practice Address - Phone:203-933-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0015697183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist