Provider Demographics
NPI:1396499703
Name:FAQQOUSEH, AHLAM
Entity type:Individual
Prefix:
First Name:AHLAM
Middle Name:
Last Name:FAQQOUSEH
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 1:6138 9TH AVENUE CIR NE
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-9559
Mailing Address - Country:US
Mailing Address - Phone:941-726-6638
Mailing Address - Fax:
Practice Address - Street 1:6138 9TH AVENUE CIR NE
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34212-9559
Practice Address - Country:US
Practice Address - Phone:941-726-6638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS559381835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty