Provider Demographics
NPI:1578631818
Name:ABISOUROUR, MOHAMED (RPH)
Entity Type:Individual
Prefix:MR
First Name:MOHAMED
Middle Name:
Last Name:ABISOUROUR
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 1:2333 FEATHER SOUND DR
Mailing Address - Street 2:A211
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-3076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 26TH AVE EAST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:941-708-7672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS34402183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist