Provider Demographics
NPI:1639779200
Name:ELBASUNY, MOHAMED
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:ELBASUNY
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 1:1315 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1937
Mailing Address - Country:US
Mailing Address - Phone:763-682-2963
Mailing Address - Fax:
Practice Address - Street 1:1315 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1937
Practice Address - Country:US
Practice Address - Phone:763-682-2963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-31
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN117228183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist