Healthcare Provider Details

I. General information

NPI: 1295641868
Provider Name (Legal Business Name): KEVIN MIRZA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4295 ORCHARD LAKE RD
WEST BLOOMFIELD MI
48323-1642
US

IV. Provider business mailing address

4295 ORCHARD LAKE RD
WEST BLOOMFIELD MI
48323-1642
US

V. Phone/Fax

Practice location:
  • Phone: 248-626-5434
  • Fax: 248-539-0062
Mailing address:
  • Phone: 248-626-5434
  • Fax: 248-539-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302419240
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: