Healthcare Provider Details

I. General information

NPI: 1881359552
Provider Name (Legal Business Name): DR. MOHAMED ALI JALLOH JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 11/08/2021
Certification Date: 11/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3703 LAWNDALE DR
GREENSBORO NC
27455-3001
US

IV. Provider business mailing address

205 COLONNADE DR
ELON NC
27244-7676
US

V. Phone/Fax

Practice location:
  • Phone: 336-540-1344
  • Fax:
Mailing address:
  • Phone: 704-907-2405
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number30131
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: