Provider Demographics
NPI:1730536814
Name:SAMY, MOURAD
Entity type:Individual
Prefix:
First Name:MOURAD
Middle Name:
Last Name:SAMY
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 1:150 BERGEN ST # B-136
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2496
Mailing Address - Country:US
Mailing Address - Phone:973-972-5120
Mailing Address - Fax:
Practice Address - Street 1:2500 KENNEDY BLVD
Practice Address - Street 2:APT 202
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304
Practice Address - Country:US
Practice Address - Phone:423-449-9994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI03708400183500000X
NJ28RJ06080183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist