Provider Demographics
NPI:1205548039
Name:ANTOUN, MARY GAMAL GEORGE
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:GAMAL GEORGE
Last Name:ANTOUN
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 1:767 FAWNHILL RD
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19008-1521
Mailing Address - Country:US
Mailing Address - Phone:267-300-1344
Mailing Address - Fax:
Practice Address - Street 1:600 KINGS HWY N STE 7
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1535
Practice Address - Country:US
Practice Address - Phone:856-482-2282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-26
Last Update Date:2022-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI04243000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist