Healthcare Provider Details

I. General information

NPI: 1699095059
Provider Name (Legal Business Name): AMANY MOFIED KIROLLOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 06/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8760 19TH ST
ALTA LOMA CA
91701-4608
US

IV. Provider business mailing address

610 E UNION ST APT 365
PASADENA CA
91101-2092
US

V. Phone/Fax

Practice location:
  • Phone: 909-989-3235
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number55708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: