MEDICARE: KATHLEEN IDRISS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	5302043168	MI

General Provider Information

NPI Number	:	1265063937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN IDRISS

Provider Business Mailing Address
First Line	:	1935 CAMPBELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48209-2133
Country	:	US
Telephone Number	:	313-842-3410
Fax Number	:	313-841-9240

Provider Business Practice Location Address
First Line	:	1935 CAMPBELL ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48209-2133
Country	:	US
Telephone Number	:	313-842-3410
Fax Number	:	313-841-9240

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2020
Last Update Date	:	01/30/2020

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Directions to “ KATHLEEN IDRISS ” Practice Location

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