Provider Demographics
NPI:1750989216
Name:HAFEZ, HESHAM
Entity type:Individual
Prefix:MR
First Name:HESHAM
Middle Name:
Last Name:HAFEZ
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 1:3300 BRUMBACK BLVD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4815
Mailing Address - Country:US
Mailing Address - Phone:262-654-6854
Mailing Address - Fax:
Practice Address - Street 1:3300 BRUMBACK BLVD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4815
Practice Address - Country:US
Practice Address - Phone:262-654-6854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19234-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist