Healthcare Provider Details

I. General information

NPI: 1942581434
Provider Name (Legal Business Name): ALAA EDRISS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15450 MICHIGAN AVE
DEARBORN MI
48126-2917
US

IV. Provider business mailing address

15450 MICHIGAN AVE
DEARBORN MI
48126-2917
US

V. Phone/Fax

Practice location:
  • Phone: 313-584-5820
  • Fax:
Mailing address:
  • Phone: 313-584-5820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5367033117
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: