Provider Demographics
NPI:1295578102
Name:MOSTAFA, MOHAMED
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:MOSTAFA
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 1:38 OAKLAWN AVE APT 320
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02920-9369
Mailing Address - Country:US
Mailing Address - Phone:646-932-3016
Mailing Address - Fax:
Practice Address - Street 1:915 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4257
Practice Address - Country:US
Practice Address - Phone:860-446-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0016527183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist