Provider Demographics
NPI:1215676960
Name:MOUKHALLALATI, RAED
Entity type:Individual
Prefix:
First Name:RAED
Middle Name:
Last Name:MOUKHALLALATI
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 1:10807 E 3RD AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-5260
Mailing Address - Country:US
Mailing Address - Phone:509-218-9799
Mailing Address - Fax:
Practice Address - Street 1:6520 N NEVEDA ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208
Practice Address - Country:US
Practice Address - Phone:509-489-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61190155183500000X
IDP9975183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist