Provider Demographics
NPI:1831967280
Name:MOGHALES, OSAMAH T
Entity type:Individual
Prefix:MR
First Name:OSAMAH
Middle Name:T
Last Name:MOGHALES
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 1:167 CARROLL PL APT 1
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1539
Mailing Address - Country:US
Mailing Address - Phone:917-200-5225
Mailing Address - Fax:
Practice Address - Street 1:167 CARROLL PL APT 1
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-1539
Practice Address - Country:US
Practice Address - Phone:917-200-5225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-15
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RHI04348200183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist