Provider Demographics
NPI:1447077268
Name:ALTAIE, ISSRA (RPH)
Entity type:Individual
Prefix:
First Name:ISSRA
Middle Name:
Last Name:ALTAIE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11919 GARDNER PARK LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77498-7328
Mailing Address - Country:US
Mailing Address - Phone:832-475-0859
Mailing Address - Fax:
Practice Address - Street 1:1890 FM 359 RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77406-1272
Practice Address - Country:US
Practice Address - Phone:281-238-8231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist