Healthcare Provider Details

I. General information

NPI: 1568067502
Provider Name (Legal Business Name): MINA KHOUZAM PHARM D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1041 POMPTON AVE
CEDAR GROVE NJ
07009-1155
US

IV. Provider business mailing address

1041 POMPTON AVE
CEDAR GROVE NJ
07009-1155
US

V. Phone/Fax

Practice location:
  • Phone: 973-237-4061
  • Fax:
Mailing address:
  • Phone: 973-237-4061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03510300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: