Provider Demographics
NPI:1073815080
Name:MABROUK EID, AYMAN
Entity Type:Individual
Prefix:
First Name:AYMAN
Middle Name:
Last Name:MABROUK EID
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 HAHN DR
Mailing Address - Street 2:APT# 418
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-0183
Mailing Address - Country:US
Mailing Address - Phone:209-232-0834
Mailing Address - Fax:
Practice Address - Street 1:1000 W MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-0110
Practice Address - Country:US
Practice Address - Phone:209-669-9704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-23
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64872183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist