Provider Demographics
NPI:1003115262
Name:KHURRAM, MOHAMMED WAHABUDDIN (DPH)
Entity Type:Individual
Prefix:
First Name:MOHAMMED
Middle Name:WAHABUDDIN
Last Name:KHURRAM
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 POPLAR HL
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-7826
Mailing Address - Country:US
Mailing Address - Phone:931-241-9862
Mailing Address - Fax:931-906-8143
Practice Address - Street 1:2100 LOWES DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-6688
Practice Address - Country:US
Practice Address - Phone:931-906-3181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-26
Last Update Date:2011-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31794183500000X
KY013992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist