Provider Demographics
NPI:1285403246
Name:KHATIB, MOHAMED
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:KHATIB
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 1:71 SCHILLER RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 PERSHING DR
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-2214
Practice Address - Country:US
Practice Address - Phone:203-735-7837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-01
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00164951835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist