Healthcare Provider Details

I. General information

NPI: 1972127843
Provider Name (Legal Business Name): MOHAMAD HAISSAM GHAZZAOUI PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14716 W WARREN AVE
DEARBORN MI
48126-1347
US

IV. Provider business mailing address

14716 W WARREN AVE
DEARBORN MI
48126-1347
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303018068
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5351016280
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302415557
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number9672
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: