Provider Demographics
NPI:1336705573
Name:KANDIL, ADAM
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:KANDIL
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 1:1534 BRIGHTON AVE APT 17
Mailing Address - Street 2:
Mailing Address - City:GROVER BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93433-1868
Mailing Address - Country:US
Mailing Address - Phone:805-305-6565
Mailing Address - Fax:
Practice Address - Street 1:3960 BROAD ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7018
Practice Address - Country:US
Practice Address - Phone:805-783-2903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35267183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1234567Other1234567