Provider Demographics
NPI:1568250561
Name:YACOUB, MOUDI
Entity type:Individual
Prefix:
First Name:MOUDI
Middle Name:
Last Name:YACOUB
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 1:529 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-3332
Mailing Address - Country:US
Mailing Address - Phone:862-872-3153
Mailing Address - Fax:862-872-3154
Practice Address - Street 1:529 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3332
Practice Address - Country:US
Practice Address - Phone:862-872-3153
Practice Address - Fax:862-872-3154
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RW03451400183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician