Healthcare Provider Details

I. General information

NPI: 1164842670
Provider Name (Legal Business Name): PURA CLINIC FAMILY MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 BAYWOOD RD SUITE 111
FAYETTEVILLE NC
28312-8733
US

IV. Provider business mailing address

PO BOX 4860
MURRELLS INLET SC
29576-2698
US

V. Phone/Fax

Practice location:
  • Phone: 910-829-5108
  • Fax: 910-829-5107
Mailing address:
  • Phone: 843-651-2624
  • Fax: 843-357-4940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. MOHAMAD A. SHAKIR
Title or Position: OWNER
Credential: M.D.
Phone: 910-829-5108