Provider Demographics
NPI:1659976736
Name:SUCHEDINA, MOHADDISA
Entity Type:Individual
Prefix:
First Name:MOHADDISA
Middle Name:
Last Name:SUCHEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 GOLIAD WAY
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:TX
Mailing Address - Zip Code:76226-1496
Mailing Address - Country:US
Mailing Address - Phone:347-615-7639
Mailing Address - Fax:
Practice Address - Street 1:1496 FM 407
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-2125
Practice Address - Country:US
Practice Address - Phone:972-317-2392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX61624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist