Provider Demographics
NPI:1356919385
Name:EL DOMIATY, HEPA ALY
Entity type:Individual
Prefix:
First Name:HEPA
Middle Name:ALY
Last Name:EL DOMIATY
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 1:3922 WILLIS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4911
Mailing Address - Country:US
Mailing Address - Phone:502-408-2282
Mailing Address - Fax:
Practice Address - Street 1:3922 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4911
Practice Address - Country:US
Practice Address - Phone:502-690-4462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY021999183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist