MEDICARE: DMZ PHARMACY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336C0003X	Community/Retail Pharmacy	5301010378	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2144388	OTHER		PK

General Provider Information

NPI Number	:	1467879759
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DMZ PHARMACY LLC

Provider Business Mailing Address
First Line	:	24355 FORD RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1129
Country	:	US
Telephone Number	:	313-563-7777
Fax Number	:

Provider Business Practice Location Address
First Line	:	24355 FORD RD
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48128-1129
Country	:	US
Telephone Number	:	313-563-7777
Fax Number	:	313-563-3677

Authorized Official
Title or Position	:	OWNER/PHARMACIST
Name	:	TALAL MAISARI
Credential	:
Telephone Number	:	313-204-3455

Provider Enumeration Date	:	03/25/2014
Last Update Date	:	12/01/2015

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Directions to “DMZ PHARMACY LLC ” Practice Location

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