Provider Demographics
NPI:1194134833
Name:MOUSA, MICHAEL (PHARMD, RPH)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:MOUSA
Suffix:
Gender:M
Credentials:PHARMD, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-5204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1630 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-5204
Practice Address - Country:US
Practice Address - Phone:619-590-4271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-07
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03331088183500000X
CA67055183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist