Provider Demographics
NPI:1366151656
Name:TARIK, MUSTAFA A
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:A
Last Name:TARIK
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 1:292 SPECTRUM RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-0902
Mailing Address - Country:US
Mailing Address - Phone:843-801-5696
Mailing Address - Fax:843-801-5696
Practice Address - Street 1:1120 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7326
Practice Address - Country:US
Practice Address - Phone:843-821-7537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43747183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist