MEDICARE: ELIZABETH MOHAM PHARMD, PSYD

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	28RI03023600	NJ

General Provider Information

NPI Number	:	1558963678
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH MOHAM PHARMD, PSYD

Provider Business Mailing Address
First Line	:	126 HIMMELIEN RD
Second Line	:
City	:	MEDFORD
State	:	NJ
Zip	:	08055-9300
Country	:	US
Telephone Number	:	856-630-4763
Fax Number	:

Provider Business Practice Location Address
First Line	:	5756 HARTFORD ST & POINTVILLE ROAD
Second Line	:
City	:	JOINT BASE MDL
State	:	NJ
Zip	:	08640
Country	:	US
Telephone Number	:	609-723-1100
Fax Number	:

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

Provider Enumeration Date	:	11/13/2020
Last Update Date	:	11/13/2020

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