Provider Demographics
NPI:1053693879
Name:MARZOUK, WAFIK A (RPH)
Entity type:Individual
Prefix:
First Name:WAFIK
Middle Name:A
Last Name:MARZOUK
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 1:2825 S WASHINGTON AVENUE
Mailing Address - Street 2:658
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-1713
Mailing Address - Country:US
Mailing Address - Phone:321-269-7573
Mailing Address - Fax:
Practice Address - Street 1:4600 S WASHINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:321-269-7573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-19
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS42569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist