Provider Demographics
NPI:1790232791
Name:HAFEZ, FADY
Entity Type:Individual
Prefix:
First Name:FADY
Middle Name:
Last Name:HAFEZ
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 1:14515 MOJAVE DR STE B
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-6762
Mailing Address - Country:US
Mailing Address - Phone:909-471-2841
Mailing Address - Fax:
Practice Address - Street 1:27177 STATE HIGHWAY 189
Practice Address - Street 2:
Practice Address - City:BLUE JAY
Practice Address - State:CA
Practice Address - Zip Code:92317-0017
Practice Address - Country:US
Practice Address - Phone:909-336-1275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-07
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72647183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist