MEDICARE: IBTISAM WHITE

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	5302029995	MI

General Provider Information

NPI Number	:	1669886198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IBTISAM WHITE

Provider Business Mailing Address
First Line	:	3050 UNION LAKE RD
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48382-4509
Country	:	US
Telephone Number	:	248-363-4392
Fax Number	:	248-363-7723

Provider Business Practice Location Address
First Line	:	3050 UNION LAKE RD
Second Line	:
City	:	COMMERCE TWP
State	:	MI
Zip	:	48382-4509
Country	:	US
Telephone Number	:	248-363-4392
Fax Number	:	248-363-7723

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

Provider Enumeration Date	:	06/12/2014
Last Update Date	:	06/12/2014

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Directions to “ IBTISAM WHITE ” Practice Location

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