Provider Demographics
NPI:1588251862
Name:KOLEILAT, MUHIEDDINE MUHAMMAD (PHARMACIST)
Entity type:Individual
Prefix:MR
First Name:MUHIEDDINE
Middle Name:MUHAMMAD
Last Name:KOLEILAT
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 STATE ROAD 312 W
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4201
Mailing Address - Country:US
Mailing Address - Phone:904-824-6167
Mailing Address - Fax:904-824-2015
Practice Address - Street 1:175 STATE ROAD 312 W
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4201
Practice Address - Country:US
Practice Address - Phone:904-824-6167
Practice Address - Fax:904-824-2015
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS23698183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist