Healthcare Provider Details

I. General information

NPI: 1689204471
Provider Name (Legal Business Name): ADVANCED PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 07/09/2020
Certification Date: 07/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13530 MICHIGAN AVE # L2
DEARBORN MI
48126-3574
US

IV. Provider business mailing address

317 MONTESANO PARK DR
IMPERIAL MO
63052-2469
US

V. Phone/Fax

Practice location:
  • Phone: 734-664-1147
  • Fax:
Mailing address:
  • Phone: 573-579-3360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. TAREK MAZLOUM
Title or Position: PHARMACIST
Credential: RPH
Phone: 734-664-1147