Provider Demographics
NPI:1700499878
Name:EL ASSOUAD, RAGHEB
Entity Type:Individual
Prefix:
First Name:RAGHEB
Middle Name:
Last Name:EL ASSOUAD
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 1:1525 N VETERAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704
Mailing Address - Country:US
Mailing Address - Phone:309-661-8613
Mailing Address - Fax:
Practice Address - Street 1:1525 N VETERANS PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-0904
Practice Address - Country:US
Practice Address - Phone:309-661-8613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051303195183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist