Provider Demographics
NPI:1356800866
Name:ELDASH, MOHAMAD AMR MOHAMAD ABDELHAM
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:AMR MOHAMAD ABDELHAM
Last Name:ELDASH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12801 FAIR OAKS BLVD APT 482
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-5221
Mailing Address - Country:US
Mailing Address - Phone:201-626-8761
Mailing Address - Fax:
Practice Address - Street 1:12801 FAIR OAKS BLVD APT 482
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-5221
Practice Address - Country:US
Practice Address - Phone:201-626-8761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44069183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist