Provider Demographics
NPI:1609090307
Name:ELASSAL, MENA
Entity Type:Individual
Prefix:
First Name:MENA
Middle Name:
Last Name:ELASSAL
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 1:3460 DIAMOND LEAF LN
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32766-7026
Mailing Address - Country:US
Mailing Address - Phone:419-508-0176
Mailing Address - Fax:
Practice Address - Street 1:839 N ORLANDO AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-2921
Practice Address - Country:US
Practice Address - Phone:407-647-1862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57222183500000X
OH03-1-27585183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist