Provider Demographics
NPI:1427577048
Name:MOURTADA, FAWZIEH
Entity Type:Individual
Prefix:
First Name:FAWZIEH
Middle Name:
Last Name:MOURTADA
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 1:540 W 235TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-1709
Mailing Address - Country:US
Mailing Address - Phone:718-548-8600
Mailing Address - Fax:
Practice Address - Street 1:RITE AID
Practice Address - Street 2:540 WEST 235TH STREET
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10643
Practice Address - Country:US
Practice Address - Phone:718-548-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0614551835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist