Provider Demographics
NPI:1013566538
Name:MIAH, SIPU (RPH)
Entity Type:Individual
Prefix:
First Name:SIPU
Middle Name:
Last Name:MIAH
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26820 GROBBEL AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48091-1262
Mailing Address - Country:US
Mailing Address - Phone:313-633-4579
Mailing Address - Fax:
Practice Address - Street 1:7843 W VERNOR HWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-1517
Practice Address - Country:US
Practice Address - Phone:313-554-4491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411784183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist