Provider Demographics
NPI:1932970514
Name:MOHAMMED DAFALLA, MONTASER AHMED (RPH)
Entity Type:Individual
Prefix:
First Name:MONTASER
Middle Name:AHMED
Last Name:MOHAMMED DAFALLA
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 1:4204 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9353
Mailing Address - Country:US
Mailing Address - Phone:336-912-6466
Mailing Address - Fax:
Practice Address - Street 1:300 E CORNWALLIS DR
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-5104
Practice Address - Country:US
Practice Address - Phone:336-275-9471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC328553336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy