Healthcare Provider Details

I. General information

NPI: 1760793640
Provider Name (Legal Business Name): BLAND JOHN KHALIFAH RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2010
Last Update Date: 06/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17170 HARPER AVE
DETROIT MI
48224-1955
US

IV. Provider business mailing address

1007 CADIEUX RD
GROSSE POINTE PARK MI
48230-1511
US

V. Phone/Fax

Practice location:
  • Phone: 313-881-3653
  • Fax: 313-882-0647
Mailing address:
  • Phone: 313-881-5374
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302022178
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: