MEDICARE: MOHAMAD IBRAHIM MUSTAPHA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302412453	MI

General Provider Information

NPI Number	:	1104412238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOHAMAD IBRAHIM MUSTAPHA

Provider Business Mailing Address
First Line	:	1780 WHITEFIELD ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-3421
Country	:	US
Telephone Number	:	313-632-6054
Fax Number	:

Provider Business Practice Location Address
First Line	:	1780 WHITEFIELD ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48127-3421
Country	:	US
Telephone Number	:	313-632-6054
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2020
Last Update Date	:	12/13/2020

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