Provider Demographics
NPI:1699200857
Name:AL SUDANY, LAITH HUSEIN ALI (RPH)
Entity Type:Individual
Prefix:
First Name:LAITH
Middle Name:HUSEIN ALI
Last Name:AL SUDANY
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:PO BOX 1647
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-1647
Mailing Address - Country:US
Mailing Address - Phone:619-456-8593
Mailing Address - Fax:
Practice Address - Street 1:787 L ST
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-2822
Practice Address - Country:US
Practice Address - Phone:619-456-8593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist