Provider Demographics
NPI:1396054623
Name:NEJADDEHGHAN, MOUSA
Entity type:Individual
Prefix:
First Name:MOUSA
Middle Name:
Last Name:NEJADDEHGHAN
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 1:5117 DURHAM RD E
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044
Mailing Address - Country:US
Mailing Address - Phone:410-917-5015
Mailing Address - Fax:
Practice Address - Street 1:140 BACK RIVER NECK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21221-3924
Practice Address - Country:US
Practice Address - Phone:410-238-0511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD12240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist