Provider Demographics
NPI:1912355975
Name:ELASSAL, FADY
Entity Type:Individual
Prefix:
First Name:FADY
Middle Name:
Last Name:ELASSAL
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 1:962 S DORSET RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-4705
Mailing Address - Country:US
Mailing Address - Phone:800-232-4239
Mailing Address - Fax:
Practice Address - Street 1:962 S DORSET RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-4705
Practice Address - Country:US
Practice Address - Phone:800-232-4239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03328384183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist