Provider Demographics
NPI:1649724162
Name:AWADALLA, OMAR M (PHARMD)
Entity type:Individual
Prefix:
First Name:OMAR
Middle Name:M
Last Name:AWADALLA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:138 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-5813
Mailing Address - Country:US
Mailing Address - Phone:516-612-9300
Mailing Address - Fax:855-777-8254
Practice Address - Street 1:138 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-5813
Practice Address - Country:US
Practice Address - Phone:516-612-9300
Practice Address - Fax:855-777-8254
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY062101183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05446837Medicaid