Provider Demographics
NPI:1275806176
Name:FAHIM, HODA M
Entity Type:Individual
Prefix:
First Name:HODA
Middle Name:M
Last Name:FAHIM
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 1:9273 LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55014
Mailing Address - Country:US
Mailing Address - Phone:763-783-7005
Mailing Address - Fax:
Practice Address - Street 1:9273 LAKE DR
Practice Address - Street 2:
Practice Address - City:CIRCLE PINES
Practice Address - State:MN
Practice Address - Zip Code:55014-3764
Practice Address - Country:US
Practice Address - Phone:763-783-7005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN116029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116029OtherPHARMACY LINSENCE #