Provider Demographics
NPI:1912749458
Name:ABDELLATIF, MENATALLA
Entity type:Individual
Prefix:
First Name:MENATALLA
Middle Name:
Last Name:ABDELLATIF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 GATEHALL LN
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2718
Mailing Address - Country:US
Mailing Address - Phone:573-772-2190
Mailing Address - Fax:
Practice Address - Street 1:10007 KENNERLY RD STE A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2179
Practice Address - Country:US
Practice Address - Phone:314-270-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-06
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020035092183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist