Provider Demographics
NPI:1770138224
Name:ULLAH, FATEH
Entity type:Individual
Prefix:
First Name:FATEH
Middle Name:
Last Name:ULLAH
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 1:125 28TH CT
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-6240
Mailing Address - Country:US
Mailing Address - Phone:515-277-6111
Mailing Address - Fax:
Practice Address - Street 1:725 S FORTUNA BLVD
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3034
Practice Address - Country:US
Practice Address - Phone:707-725-9314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-01
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist