MEDICARE: MR. MOHEMMED YUSUF GANGAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	0000012396	TN

General Provider Information

NPI Number	:	1487945820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MOHEMMED YUSUF GANGAT

Provider Business Mailing Address
First Line	:	15 LARCHMONT LN
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37604-6384
Country	:	US
Telephone Number	:	423-926-4436
Fax Number	:

Provider Business Practice Location Address
First Line	:	417 BOONES CREEK RD
Second Line	:
City	:	JONESBOROUGH
State	:	TN
Zip	:	37659-5165
Country	:	US
Telephone Number	:	423-753-9701
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	04/19/2011

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