Provider Demographics
NPI:1710518063
Name:RIZKALLA, BAHER
Entity Type:Individual
Prefix:
First Name:BAHER
Middle Name:
Last Name:RIZKALLA
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 1:3633 BENERAID ST
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-7919
Mailing Address - Country:US
Mailing Address - Phone:813-464-0563
Mailing Address - Fax:
Practice Address - Street 1:5324 LITTLE RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34655-1294
Practice Address - Country:US
Practice Address - Phone:727-375-5383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist