Provider Demographics
NPI:1851014161
Name:TAKLA, MOHAB M
Entity Type:Individual
Prefix:
First Name:MOHAB
Middle Name:M
Last Name:TAKLA
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 1:12915 CASTLEMAINE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-4471
Mailing Address - Country:US
Mailing Address - Phone:760-567-0676
Mailing Address - Fax:
Practice Address - Street 1:9202 N FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7906
Practice Address - Country:US
Practice Address - Phone:760-567-0676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS54805183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist