Provider Demographics
NPI:1053774166
Name:MOURAD, MAYA MERRYAM
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:MERRYAM
Last Name:MOURAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 NW ALTISHIN PL
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-6368
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1625 E HARBOR DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:OR
Practice Address - Zip Code:97146-9689
Practice Address - Country:US
Practice Address - Phone:503-861-9324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0015164183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist