Provider Demographics
NPI:1619575750
Name:HAKIM, HASSEN A (RPH)
Entity Type:Individual
Prefix:
First Name:HASSEN
Middle Name:A
Last Name:HAKIM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-3120
Mailing Address - Country:US
Mailing Address - Phone:574-295-4333
Mailing Address - Fax:574-522-6265
Practice Address - Street 1:230 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-3120
Practice Address - Country:US
Practice Address - Phone:574-295-4333
Practice Address - Fax:574-522-6265
Is Sole Proprietor?:No
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016625A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200804030AMedicaid