Provider Demographics
NPI:1972893667
Name:MOHAMMED, KHAJA MOHIUDDIN (RPH)
Entity Type:Individual
Prefix:MR
First Name:KHAJA
Middle Name:MOHIUDDIN
Last Name:MOHAMMED
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 SENECA DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-8833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT HOPE
Practice Address - State:WV
Practice Address - Zip Code:25880-1105
Practice Address - Country:US
Practice Address - Phone:304-877-7923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-14
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0007520183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023930Medicaid