Provider Demographics
NPI:1629505425
Name:AMMARY, WASSIM
Entity Type:Individual
Prefix:
First Name:WASSIM
Middle Name:
Last Name:AMMARY
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 1:634 N ALEXANDRIA AVE APT 11
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-2160
Mailing Address - Country:US
Mailing Address - Phone:313-449-2036
Mailing Address - Fax:
Practice Address - Street 1:1855 SOUTH FAIR OAKS AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91103
Practice Address - Country:US
Practice Address - Phone:626-993-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34835183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist