Provider Demographics
NPI:1780074690
Name:ABOUTALEB, KHALED MOHAMED (RPH)
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:MOHAMED
Last Name:ABOUTALEB
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 1:405 SE EVERETT MALL WAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-3243
Mailing Address - Country:US
Mailing Address - Phone:425-353-7967
Mailing Address - Fax:425-249-5602
Practice Address - Street 1:405 SE EVERETT MALL WAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3243
Practice Address - Country:US
Practice Address - Phone:425-353-7967
Practice Address - Fax:425-249-5602
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-29
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60458899183500000X
CA62056183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist