Provider Demographics
NPI:1013525419
Name:SHALTOUT, NOURHAN
Entity Type:Individual
Prefix:
First Name:NOURHAN
Middle Name:
Last Name:SHALTOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ANTHONY LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07004-1406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:661 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07503-3028
Practice Address - Country:US
Practice Address - Phone:973-307-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04097600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist