=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700348117
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARMEN BAKDALEYEH PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 04/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11493 N LINDEN RD
-----------------------------------------------------
City | CLIO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48420-8586
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-564-4278
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6932 COOLEY LAKE RD
-----------------------------------------------------
City | WHITE LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48383-3406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-767-2416
-----------------------------------------------------
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 | 5302042836
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------