Provider Demographics
NPI:1083219547
Name:IMANOEL, MAHROKH
Entity Type:Individual
Prefix:
First Name:MAHROKH
Middle Name:
Last Name:IMANOEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-3632
Mailing Address - Country:US
Mailing Address - Phone:410-737-8820
Mailing Address - Fax:410-737-8829
Practice Address - Street 1:6601 AMLEIGH RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21209-2603
Practice Address - Country:US
Practice Address - Phone:410-978-7977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45198183500000X
MD12487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist