Provider Demographics
NPI:1891465522
Name:SARSOUR, OBADA S I (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:OBADA
Middle Name:S
Last Name:SARSOUR
Suffix:I
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7165 S BALLPARK DR
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-6920
Mailing Address - Country:US
Mailing Address - Phone:414-334-6428
Mailing Address - Fax:
Practice Address - Street 1:2205 N CALHOUN RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5062
Practice Address - Country:US
Practice Address - Phone:262-782-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2114440183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist