MEDICARE: MOSTAFA MOHAMED ABOUTALEB PHARMD

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	5302041594	MI

General Provider Information

NPI Number	:	1700417318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOSTAFA MOHAMED ABOUTALEB PHARMD

Provider Business Mailing Address
First Line	:	16645 MAYFIELD ST
Second Line	:
City	:	LIVONIA
State	:	MI
Zip	:	48154-2963
Country	:	US
Telephone Number	:	313-587-3631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1935 CAMPBELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48209-2133
Country	:	US
Telephone Number	:	313-587-3631
Fax Number	:

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

Provider Enumeration Date	:	02/01/2020
Last Update Date	:	02/01/2020

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