Provider Demographics
NPI:1902448053
Name:ELJAROUCH, AHMAD (RPH)
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:ELJAROUCH
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 1:664 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-3124
Mailing Address - Country:US
Mailing Address - Phone:508-755-3000
Mailing Address - Fax:508-755-7778
Practice Address - Street 1:54 HARVARD STREET EXT APT 1
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-3524
Practice Address - Country:US
Practice Address - Phone:413-433-1135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPH235794183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1477851798Medicaid