{
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"ParentOrgTIN": null,
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"LastName": null,
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"NamePrefix": null,
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"FirstLineMailingAddress": "13700 E 12 MILE RD",
"SecondLineMailingAddress": "PMB 104",
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"MailingAddressPostalCode": "48088",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "248-829-7799",
"MailingAddressFaxNumber": "248-829-7975",
"FirstLinePracticeLocationAddress": "25775 W 10 MILE RD STE C",
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"PracticeLocationAddressCityName": "SOUTHFIELD",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "248-829-7799",
"PracticeLocationAddressFaxNumber": "248-829-7975",
"EnumerationDate": "09/04/2026",
"LastUpdateDate": "09/04/2026",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MANSOUR",
"AuthorizedOfficialFirstName": "ABBAS",
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"AuthorizedOfficialTitle": "OWNER",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "248-829-7799",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}