Provider Demographics
NPI:1932817343
Name:ELKAISSI, AUSAM MONAF (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:AUSAM
Middle Name:MONAF
Last Name:ELKAISSI
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 RED CEDAR DR APT 11
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-7640
Mailing Address - Country:US
Mailing Address - Phone:313-899-8018
Mailing Address - Fax:
Practice Address - Street 1:15880 SUMMERLIN RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9612
Practice Address - Country:US
Practice Address - Phone:239-433-0297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL65137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL65137OtherPHARMACY LICENSE NUMBER
FL1400925OtherNATIONAL ASSOCIATION OF BOARDS OF PHARMACY