Provider Demographics
NPI:1083221642
Name:DEZA, ANITA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:DEZA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36485 GARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-1132
Mailing Address - Country:US
Mailing Address - Phone:586-791-0738
Mailing Address - Fax:
Practice Address - Street 1:36485 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-1132
Practice Address - Country:US
Practice Address - Phone:586-791-0738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412957183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist