Provider Demographics
NPI:1073038543
Name:BENRAHLA, MUSTAFA (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:BENRAHLA
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 ERNEST ST APT 345
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-8479
Mailing Address - Country:US
Mailing Address - Phone:504-931-6551
Mailing Address - Fax:
Practice Address - Street 1:2825 RYAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-7329
Practice Address - Country:US
Practice Address - Phone:337-494-1590
Practice Address - Fax:337-437-7639
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-07
Last Update Date:2017-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020907183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist