Provider Demographics
NPI:1659956498
Name:ELABBADI, SAMIR
Entity Type:Individual
Prefix:
First Name:SAMIR
Middle Name:
Last Name:ELABBADI
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 1:214 PINE SHORE DR APT 54
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-7505
Mailing Address - Country:US
Mailing Address - Phone:773-990-9717
Mailing Address - Fax:
Practice Address - Street 1:501 N GIANT CITY RD
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62902-6417
Practice Address - Country:US
Practice Address - Phone:618-457-5313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-12
Last Update Date:2021-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303756183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist