Provider Demographics
NPI:1104579507
Name:ELHASSANNY, AHMED ELWAN MOHAMED
Entity type:Individual
Prefix:
First Name:AHMED
Middle Name:ELWAN MOHAMED
Last Name:ELHASSANNY
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 1:121 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PEARISBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24134-1624
Mailing Address - Country:US
Mailing Address - Phone:540-921-1284
Mailing Address - Fax:
Practice Address - Street 1:121 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PEARISBURG
Practice Address - State:VA
Practice Address - Zip Code:24134-1624
Practice Address - Country:US
Practice Address - Phone:540-921-1284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202220002183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist