Healthcare Provider Details

I. General information

NPI: 1265063937
Provider Name (Legal Business Name): KATHLEEN IDRISS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 CAMPBELL ST
DETROIT MI
48209-2133
US

IV. Provider business mailing address

1935 CAMPBELL ST
DETROIT MI
48209-2133
US

V. Phone/Fax

Practice location:
  • Phone: 313-842-3410
  • Fax: 313-841-9240
Mailing address:
  • Phone: 313-842-3410
  • Fax: 313-841-9240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302043168
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: