Provider Demographics
NPI:1629450358
Name:FAHIM, MEDHAT
Entity Type:Individual
Prefix:
First Name:MEDHAT
Middle Name:
Last Name:FAHIM
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 1:27702 CROWN VALLEY PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:LADERA RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92694-0609
Mailing Address - Country:US
Mailing Address - Phone:949-364-2098
Mailing Address - Fax:949-364-2198
Practice Address - Street 1:27702 CROWN VALLY # B
Practice Address - Street 2:
Practice Address - City:LADERA RANCH
Practice Address - State:CA
Practice Address - Zip Code:92694
Practice Address - Country:US
Practice Address - Phone:949-364-2098
Practice Address - Fax:948-364-2198
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist