Provider Demographics
NPI:1932621463
Name:AL-KALAK, ANNAS
Entity Type:Individual
Prefix:
First Name:ANNAS
Middle Name:
Last Name:AL-KALAK
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 1:67 EVERGREEN AVE APT B5
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-3156
Mailing Address - Country:US
Mailing Address - Phone:203-909-2627
Mailing Address - Fax:
Practice Address - Street 1:839 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-3922
Practice Address - Country:US
Practice Address - Phone:860-582-8167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0013607183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist