Provider Demographics
NPI:1588079636
Name:MOUSTAFA, KHALED
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:MOUSTAFA
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 1:548 CC CAMP RD
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-8704
Mailing Address - Country:US
Mailing Address - Phone:336-526-2640
Mailing Address - Fax:336-526-2669
Practice Address - Street 1:548 CC CAMP RD
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-8704
Practice Address - Country:US
Practice Address - Phone:336-526-2640
Practice Address - Fax:336-526-2669
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-27
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist