Provider Demographics
NPI:1104412238
Name:MUSTAPHA, MOHAMAD IBRAHIM
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:IBRAHIM
Last Name:MUSTAPHA
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 1:1780 WHITEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3421
Mailing Address - Country:US
Mailing Address - Phone:313-632-6054
Mailing Address - Fax:
Practice Address - Street 1:1780 WHITEFIELD ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3421
Practice Address - Country:US
Practice Address - Phone:313-632-6054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2020-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412453183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist