Provider Demographics
NPI:1194590935
Name:AWADALLA, MARWAN
Entity type:Individual
Prefix:
First Name:MARWAN
Middle Name:
Last Name:AWADALLA
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 1:6242 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-1929
Mailing Address - Country:US
Mailing Address - Phone:718-310-6120
Mailing Address - Fax:888-518-5120
Practice Address - Street 1:6242 FOREST AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1929
Practice Address - Country:US
Practice Address - Phone:718-310-6120
Practice Address - Fax:888-518-5120
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2024-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist