Provider Demographics
NPI:1861093155
Name:BAH, MOHAMED J
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:J
Last Name:BAH
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 1:4221 ATLANTA HWY
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7316
Mailing Address - Country:US
Mailing Address - Phone:770-554-6785
Mailing Address - Fax:
Practice Address - Street 1:2965 OLIVINE DR
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-7646
Practice Address - Country:US
Practice Address - Phone:301-275-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARPH023369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist