Provider Demographics
NPI:1629722319
Name:FARAG, HOSSAM
Entity Type:Individual
Prefix:
First Name:HOSSAM
Middle Name:
Last Name:FARAG
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 1:594B BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2510
Mailing Address - Country:US
Mailing Address - Phone:484-358-2118
Mailing Address - Fax:
Practice Address - Street 1:594B BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2510
Practice Address - Country:US
Practice Address - Phone:484-358-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03786700183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty