Healthcare Provider Details

I. General information

NPI: 1639637135
Provider Name (Legal Business Name): BASSAM HARATI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14533 LIVERNOIS AVENUE
DETROIT MI
48238-2010
US

IV. Provider business mailing address

14533 LIVERNOIS AVE
DETROIT MI
48238-2010
US

V. Phone/Fax

Practice location:
  • Phone: 313-340-7777
  • Fax: 313-340-4449
Mailing address:
  • Phone: 313-340-7777
  • Fax: 313-340-4449

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5302035339
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: