=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558774703
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHIDOZIE ENWERE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2014
-----------------------------------------------------
Last Update Date | 06/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30272 WARREN RD J66
-----------------------------------------------------
City | WESTLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48185-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-297-0761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13939 LIVERNOIS AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48238-2519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-934-0150
-----------------------------------------------------
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 | 5302036481
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------