{
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"EIN": null,
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"IsOrgSubpart": "N",
"ParentOrgLBN": null,
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"LastName": null,
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"NamePrefix": null,
"NameSuffix": null,
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"OtherLastName": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "15120 MICHIGAN AVE",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "DEARBORN",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "48126-3768",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "313-733-8034",
"MailingAddressFaxNumber": null,
"FirstLinePracticeLocationAddress": "15120 MICHIGAN AVE",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "DEARBORN",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "313-733-8043",
"PracticeLocationAddressFaxNumber": "313-733-8037",
"EnumerationDate": "06/02/2020",
"LastUpdateDate": "04/19/2024",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "SALEH",
"AuthorizedOfficialFirstName": "BANDAR",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "PHARMACIST",
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"AuthorizedOfficialNameSuffix": null,
"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "313-733-8043",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "3336C0003X",
"TaxonomyName": "Community/Retail Pharmacy",
"LicenseNumber": null,
"LicenseNumberStateCode": null,
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}