Provider Demographics
NPI:1174923361
Name:FADL, MOHAMED (RPH)
Entity type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:
Last Name:FADL
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 1:6303 WOODCHASE CT
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-7949
Mailing Address - Country:US
Mailing Address - Phone:186-290-2371
Mailing Address - Fax:
Practice Address - Street 1:6303 WOODCHASE CT
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-7949
Practice Address - Country:US
Practice Address - Phone:186-290-2371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist