Basic Information
Provider Information | |||||||||
NPI: | 1467040915 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALQEMARY | ||||||||
FirstName: | MOSTAFA | ||||||||
MiddleName: | N | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHARMACIST | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3290 CHINO HILLS PKWY | ||||||||
Address2: |   | ||||||||
City: | CHINO HILLS | ||||||||
State: | CA | ||||||||
PostalCode: | 917094270 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9095973898 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 808 W 58TH ST | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900373632 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3235411600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/08/2021 | ||||||||
LastUpdateDate: | 05/17/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/17/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 82382 | CA | N |   | Pharmacy Service Providers | Pharmacist |   | 1835P1200X | 82382 | CA | N |   | Pharmacy Service Providers | Pharmacist | Pharmacotherapy | 1835P2201X | 82382 | CA | Y |   |   |   |   |
No ID Information.