=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245856277
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OMAR MOUABBI PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2020
-----------------------------------------------------
Last Update Date | 01/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2035 MONROE ST
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48124-2920
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-944-1050
-----------------------------------------------------
Fax | 313-944-1051
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 703 S ROSEDALE CT
-----------------------------------------------------
City | GROSSE POINTE WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48236-1146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-320-8027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 5302041361
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------