Provider Demographics
NPI:1043932791
Name:MANSOUR, SAHAR F
Entity Type:Individual
Prefix:
First Name:SAHAR
Middle Name:F
Last Name:MANSOUR
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 1:49140 KILKENNY DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-1790
Mailing Address - Country:US
Mailing Address - Phone:800-456-2112
Mailing Address - Fax:
Practice Address - Street 1:49140 KILKENNY DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-1790
Practice Address - Country:US
Practice Address - Phone:800-456-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53151160701835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory CareGroup - Multi-Specialty