Provider Demographics
NPI:1356574941
Name:ELATTAR, SHADY ALY ISMAIL
Entity type:Individual
Prefix:
First Name:SHADY
Middle Name:ALY ISMAIL
Last Name:ELATTAR
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 1:15 LEDGES CT
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-1851
Mailing Address - Country:US
Mailing Address - Phone:207-423-9986
Mailing Address - Fax:
Practice Address - Street 1:62 W GRAY RD
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:ME
Practice Address - Zip Code:04039-9772
Practice Address - Country:US
Practice Address - Phone:207-657-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPR5603183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist