Provider Demographics
NPI:1538710710
Name:EISSA, ANAS ELBAGIR
Entity type:Individual
Prefix:
First Name:ANAS
Middle Name:ELBAGIR
Last Name:EISSA
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 1:1316 MOUNT HERMON RD
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21804-5220
Mailing Address - Country:US
Mailing Address - Phone:410-749-0205
Mailing Address - Fax:
Practice Address - Street 1:1316 MOUNT HERMON RD
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21804-5220
Practice Address - Country:US
Practice Address - Phone:410-749-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEA1-0005396183500000X
MD26725183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist