Provider Demographics
NPI:1720647019
Name:SARSOUR, MOATH M (PHARMACIST)
Entity Type:Individual
Prefix:DR
First Name:MOATH
Middle Name:M
Last Name:SARSOUR
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 W EDGERTON AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3561
Mailing Address - Country:US
Mailing Address - Phone:414-326-0888
Mailing Address - Fax:
Practice Address - Street 1:1672 S 9TH ST UNIT D
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-3426
Practice Address - Country:US
Practice Address - Phone:414-326-0888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1856740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist