Provider Demographics
NPI:1558963678
Name:MOHAM, ELIZABETH (PHARMD, PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:MOHAM
Suffix:
Gender:F
Credentials:PHARMD, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 HIMMELIEN RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9300
Mailing Address - Country:US
Mailing Address - Phone:856-630-4763
Mailing Address - Fax:
Practice Address - Street 1:5756 HARTFORD ST & POINTVILLE ROAD
Practice Address - Street 2:
Practice Address - City:JOINT BASE MDL
Practice Address - State:NJ
Practice Address - Zip Code:08640
Practice Address - Country:US
Practice Address - Phone:609-723-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03023600183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist