Provider Demographics
NPI:1104593490
Name:MOHAMUD, MARYAM (PHARMD)
Entity type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:MOHAMUD
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 COUNTY ROAD C2 W APT 230
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-1034
Mailing Address - Country:US
Mailing Address - Phone:612-913-2582
Mailing Address - Fax:
Practice Address - Street 1:2650 HENNEPIN AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-1149
Practice Address - Country:US
Practice Address - Phone:612-377-3308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125263183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist