Provider Demographics
NPI:1275350985
Name:JOBE, MUSTAPHA
Entity type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:
Last Name:JOBE
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 1:1265 GOSS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2271
Mailing Address - Country:US
Mailing Address - Phone:502-634-0724
Mailing Address - Fax:
Practice Address - Street 1:1265 GOSS AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-2271
Practice Address - Country:US
Practice Address - Phone:502-634-0724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY024658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist