Healthcare Provider Details

I. General information

NPI: 1790562619
Provider Name (Legal Business Name): ALEJANDRO RAUL DOMINICI CPHT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2023
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24463 W 10 MILE RD
SOUTHFIELD MI
48033-2931
US

IV. Provider business mailing address

9357 RIVERVIEW
REDFORD MI
48239-1249
US

V. Phone/Fax

Practice location:
  • Phone: 855-445-4554
  • Fax:
Mailing address:
  • Phone: 313-909-3544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number5303039558
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: