Provider Demographics
NPI:1518452242
Name:CHALATI, MUDAR
Entity Type:Individual
Prefix:
First Name:MUDAR
Middle Name:
Last Name:CHALATI
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 1:507 N LYNORA ST APT C27
Mailing Address - Street 2:
Mailing Address - City:TULARE
Mailing Address - State:CA
Mailing Address - Zip Code:93274-2954
Mailing Address - Country:US
Mailing Address - Phone:216-681-9513
Mailing Address - Fax:
Practice Address - Street 1:507 N LYNORA ST APT C27
Practice Address - Street 2:
Practice Address - City:TULARE
Practice Address - State:CA
Practice Address - Zip Code:93274-2954
Practice Address - Country:US
Practice Address - Phone:216-681-9513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPHCY-04337183500000X
MAPH237710183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHPHCY-04337OtherNH BOARD OF PHARMACY
MAPH237710OtherMA BOARD OF PHARNACY