Provider Demographics
NPI:1417558461
Name:MOHAMED, NIZAMUDEEN
Entity Type:Individual
Prefix:
First Name:NIZAMUDEEN
Middle Name:
Last Name:MOHAMED
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 1:73 BLANCHARD RD
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2918
Mailing Address - Country:US
Mailing Address - Phone:215-817-1142
Mailing Address - Fax:
Practice Address - Street 1:1 COOPERTOWNE BLVD
Practice Address - Street 2:
Practice Address - City:SOMERDALE
Practice Address - State:NJ
Practice Address - Zip Code:08083-1433
Practice Address - Country:US
Practice Address - Phone:856-545-9074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03101500183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist