Provider Demographics
NPI:1740969971
Name:AWADALLA, MUSTAFA (PHARMD)
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:
Last Name:AWADALLA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N CENTER AVE APT 7304
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5520
Mailing Address - Country:US
Mailing Address - Phone:714-591-3974
Mailing Address - Fax:
Practice Address - Street 1:10800 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3043
Practice Address - Country:US
Practice Address - Phone:714-591-3974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA88094183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist