Healthcare Provider Details

I. General information

NPI: 1417467754
Provider Name (Legal Business Name): HOSAM ABDELMONAIM ELBAZ PHD, RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2017
Last Update Date: 09/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 E GRAND RIVER AVE
EAST LANSING MI
48823-4913
US

IV. Provider business mailing address

1399 E GRAND RIVER AVE
EAST LANSING MI
48823-4913
US

V. Phone/Fax

Practice location:
  • Phone: 517-337-1385
  • Fax:
Mailing address:
  • Phone: 517-337-1385
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number5302044696
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: