Provider Demographics
NPI:1700477361
Name:FADHIL, OSAMAH
Entity Type:Individual
Prefix:
First Name:OSAMAH
Middle Name:
Last Name:FADHIL
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 1:4160 LA VALSE ST APT 3212
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-0244
Mailing Address - Country:US
Mailing Address - Phone:346-402-8469
Mailing Address - Fax:
Practice Address - Street 1:4160 LA VALSE ST APT 3212
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75052-0244
Practice Address - Country:US
Practice Address - Phone:346-402-8469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX68118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist