Provider Demographics
NPI:1700407350
Name:BANOUB, EMAD
Entity Type:Individual
Prefix:
First Name:EMAD
Middle Name:
Last Name:BANOUB
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 1:1514 ENNIS JOSLIN RD APT 626
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-2112
Mailing Address - Country:US
Mailing Address - Phone:469-831-7002
Mailing Address - Fax:
Practice Address - Street 1:1105 HYW 181
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374
Practice Address - Country:US
Practice Address - Phone:361-229-7251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66273183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist