Healthcare Provider Details

I. General information

NPI: 1215022710
Provider Name (Legal Business Name): MR. HAISSAM GHAZZAOUI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14716 WEST WARREN
DEARBORN MI
48126
US

IV. Provider business mailing address

666 DOVER
DEARBORN HEIGHTS MI
48127
US

V. Phone/Fax

Practice location:
  • Phone: 313-582-1350
  • Fax:
Mailing address:
  • Phone: 313-274-2127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302028839
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: