Provider Demographics
NPI:1508156787
Name:MUSTAFA, FATIMA
Entity Type:Individual
Prefix:
First Name:FATIMA
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 1:10200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-6399
Mailing Address - Country:US
Mailing Address - Phone:763-545-1916
Mailing Address - Fax:763-545-8056
Practice Address - Street 1:10200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-6399
Practice Address - Country:US
Practice Address - Phone:763-545-1916
Practice Address - Fax:763-545-8056
Is Sole Proprietor?:No
Enumeration Date:2011-04-08
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121144183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist