Provider Demographics
NPI:1154020923
Name:MUSTAFA, JWAN M (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JWAN
Middle Name:M
Last Name:MUSTAFA
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:PO BOX 142
Mailing Address - Street 2:
Mailing Address - City:TOHATCHI
Mailing Address - State:NM
Mailing Address - Zip Code:87325-0142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 142
Practice Address - Street 2:
Practice Address - City:TOHATCHI
Practice Address - State:NM
Practice Address - Zip Code:87325-0142
Practice Address - Country:US
Practice Address - Phone:505-733-8415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-01
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP10029183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDP10029OtherPHARMACIST