Provider Demographics
NPI:1770641540
Name:MOURAD, IMAD K (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:K
Last Name:MOURAD
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 LAGRANGE ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43608-1801
Mailing Address - Country:US
Mailing Address - Phone:419-241-8065
Mailing Address - Fax:419-242-1127
Practice Address - Street 1:3103 LAGRANGE ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-1801
Practice Address - Country:US
Practice Address - Phone:419-241-8065
Practice Address - Fax:419-242-1127
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03120964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH03120964OtherPHARMACIST LICENSE NUMBER