Provider Demographics
NPI:1013548114
Name:ISSA, DINA
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:
Last Name:ISSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26026 W 12 MILE RD # OAD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1783
Mailing Address - Country:US
Mailing Address - Phone:248-350-0280
Mailing Address - Fax:
Practice Address - Street 1:26026 W 12 MILE RD # OAD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1783
Practice Address - Country:US
Practice Address - Phone:248-350-0280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035352183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist