Provider Demographics
NPI:1770259442
Name:FALLOUH, HATEM
Entity Type:Individual
Prefix:
First Name:HATEM
Middle Name:
Last Name:FALLOUH
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 1:15 S SHAFER ST APT 401
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-2770
Mailing Address - Country:US
Mailing Address - Phone:734-299-6387
Mailing Address - Fax:
Practice Address - Street 1:555 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2104
Practice Address - Country:US
Practice Address - Phone:740-593-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH034407333336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy