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General NPI Number Information
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NPI Number | 1124682893
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Entity Type | Individual
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Provider Name | ALI FARDOUS RPH
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Gender | Male
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Dates
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Enumeration Date | 04/27/2019
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Last Update Date | 04/27/2019
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Provider Practice Location Address
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Address Line | 7555 TELEGRAPH RD
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City | TAYLOR
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State | MI
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Zip | 48180-2239
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Country | US
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Telephone | 313-292-5014
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Fax |
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Provider Business Mailing Address
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Address Line | 22822 WILSON AVE
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City | DEARBORN
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State | MI
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Zip | 48128-1851
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Country | US
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Telephone | 313-523-6011
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 5302033826
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License Number State | MI
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