Healthcare Provider Details

I. General information

NPI: 1770641540
Provider Name (Legal Business Name): IMAD K MOURAD PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 LAGRANGE ST
TOLEDO OH
43608-1801
US

IV. Provider business mailing address

3103 LAGRANGE ST
TOLEDO OH
43608-1801
US

V. Phone/Fax

Practice location:
  • Phone: 419-241-8065
  • Fax: 419-242-1127
Mailing address:
  • Phone: 419-241-8065
  • Fax: 419-242-1127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number03120964
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: