Provider Demographics
NPI:1013436104
Name:HAYAT PHARMACY 15 REMOTE DISPENSING SITE
Entity Type:Organization
Organization Name:HAYAT PHARMACY 15 REMOTE DISPENSING SITE
Other - Org Name:HAYAT PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:FATIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-454-9798
Mailing Address - Street 1:PO BOX 13337
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53213-0337
Mailing Address - Country:US
Mailing Address - Phone:414-374-0000
Mailing Address - Fax:414-374-0001
Practice Address - Street 1:1001 CECELIA DR STE 200A
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-2546
Practice Address - Country:US
Practice Address - Phone:414-374-0000
Practice Address - Fax:414-374-0001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HAYAT PHARMACY 12
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-09-11
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1000154415Medicaid