Provider Demographics
NPI:1578040788
Name:KHALED, MOTASSAM
Entity Type:Individual
Prefix:MR
First Name:MOTASSAM
Middle Name:
Last Name:KHALED
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 1:12849 E SAHUARO DR
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-4445
Mailing Address - Country:US
Mailing Address - Phone:602-741-0117
Mailing Address - Fax:
Practice Address - Street 1:10 E DUNLAP AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2821
Practice Address - Country:US
Practice Address - Phone:602-371-3709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS11510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist