Provider Demographics
NPI:1508267261
Name:MOHAMED, MOHAMED (RPH)
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:MOHAMED
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 TALCOTTVILLE RD
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4705
Mailing Address - Country:US
Mailing Address - Phone:860-633-4668
Mailing Address - Fax:
Practice Address - Street 1:242 TALCOTTVILLE RD
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4631
Practice Address - Country:US
Practice Address - Phone:860-871-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0007458183500000X
FL28RI02232100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist