Provider Demographics
NPI:1811396831
Name:BRAKTA, MOHAMED
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:BRAKTA
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 1:9 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-6632
Mailing Address - Country:US
Mailing Address - Phone:504-201-2639
Mailing Address - Fax:
Practice Address - Street 1:9 DOGWOOD DR
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-6632
Practice Address - Country:US
Practice Address - Phone:504-201-2639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA17426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist