Provider Demographics
NPI:1063756872
Name:ESHAK, WASEM (RPH)
Entity type:Individual
Prefix:MR
First Name:WASEM
Middle Name:
Last Name:ESHAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7742 DARBY AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335
Mailing Address - Country:US
Mailing Address - Phone:310-210-0142
Mailing Address - Fax:
Practice Address - Street 1:7742 DARBY AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:310-210-0142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59848183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist