Healthcare Provider Details

I. General information

NPI: 1720683436
Provider Name (Legal Business Name): MARY KAMAL FARAG GHOBRIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11101 US HIGHWAY 380
CROSSROADS TX
76227-8203
US

IV. Provider business mailing address

11101 US HIGHWAY 380
CROSSROADS TX
76227-8203
US

V. Phone/Fax

Practice location:
  • Phone: 940-365-5762
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number62386
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: