Healthcare Provider Details

I. General information

NPI: 1568250561
Provider Name (Legal Business Name): MOUDI YACOUB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2025
Last Update Date: 04/29/2025
Certification Date: 04/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 WASHINGTON AVE
BELLEVILLE NJ
07109-3332
US

IV. Provider business mailing address

529 WASHINGTON AVE
BELLEVILLE NJ
07109-3332
US

V. Phone/Fax

Practice location:
  • Phone: 862-872-3153
  • Fax: 862-872-3154
Mailing address:
  • Phone: 862-872-3153
  • Fax: 862-872-3154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number28RW03451400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: