Provider Demographics
NPI:1770007999
Name:AL-QAZZAZ, ANAS (RPH)
Entity Type:Individual
Prefix:
First Name:ANAS
Middle Name:
Last Name:AL-QAZZAZ
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 1:1400 BODEGA WAY UNIT 2
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2596
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 BODEGA WAY UNIT 2
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2596
Practice Address - Country:US
Practice Address - Phone:562-977-7402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-29
Last Update Date:2017-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist