Provider Demographics
NPI:1073239794
Name:EL-MOUSSA, ENAS
Entity Type:Individual
Prefix:
First Name:ENAS
Middle Name:
Last Name:EL-MOUSSA
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 1:15411 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2681
Mailing Address - Country:US
Mailing Address - Phone:313-520-6694
Mailing Address - Fax:
Practice Address - Street 1:15411 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2681
Practice Address - Country:US
Practice Address - Phone:313-386-8604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-14
Last Update Date:2022-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5351016633183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist