Provider Demographics
NPI:1386454304
Name:MQATASH, MODAFAR ABDALLA AYED (PHARMD)
Entity type:Individual
Prefix:DR
First Name:MODAFAR
Middle Name:ABDALLA AYED
Last Name:MQATASH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2096 BLUEBIRD WAY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-2302
Mailing Address - Country:US
Mailing Address - Phone:916-699-5971
Mailing Address - Fax:
Practice Address - Street 1:291 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2306
Practice Address - Country:US
Practice Address - Phone:707-778-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH90625183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist