Provider Demographics
NPI:1952795916
Name:KHALAFALLA, MOHSEN
Entity Type:Individual
Prefix:
First Name:MOHSEN
Middle Name:
Last Name:KHALAFALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07108-1045
Mailing Address - Country:US
Mailing Address - Phone:973-375-6003
Mailing Address - Fax:
Practice Address - Street 1:784 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07108-1045
Practice Address - Country:US
Practice Address - Phone:973-375-6003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03697400183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist