Provider Demographics
NPI:1811592587
Name:MANSURI, TARIQ
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:
Last Name:MANSURI
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 1:5002 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-1694
Mailing Address - Country:US
Mailing Address - Phone:281-557-4374
Mailing Address - Fax:
Practice Address - Street 1:5002 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-1694
Practice Address - Country:US
Practice Address - Phone:281-557-4374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67645183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist