Provider Demographics
NPI:1407442825
Name:MUSTAFA, REMAN
Entity Type:Individual
Prefix:
First Name:REMAN
Middle Name:
Last Name:MUSTAFA
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 1:5220 W RAWSON AVE
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-8806
Mailing Address - Country:US
Mailing Address - Phone:414-423-5257
Mailing Address - Fax:
Practice Address - Street 1:5220 W RAWSON AVE
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-8806
Practice Address - Country:US
Practice Address - Phone:414-423-5257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI20128-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist