Provider Demographics
NPI:1669874269
Name:AHMAD, MUTAZ (RPH)
Entity type:Individual
Prefix:
First Name:MUTAZ
Middle Name:
Last Name:AHMAD
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 1:1100 SAN BERNARDINO RD STE 1100
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4952
Mailing Address - Country:US
Mailing Address - Phone:626-546-8047
Mailing Address - Fax:
Practice Address - Street 1:1225 N HOLMAR AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-2133
Practice Address - Country:US
Practice Address - Phone:626-991-1328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA71552183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist