Provider Demographics
NPI:1083481832
Name:MAWARI, BEDERADINE
Entity Type:Individual
Prefix:
First Name:BEDERADINE
Middle Name:
Last Name:MAWARI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3322 EDSEL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1433
Mailing Address - Country:US
Mailing Address - Phone:313-491-9365
Mailing Address - Fax:
Practice Address - Street 1:15120 MICHIGAN AVE # C
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3768
Practice Address - Country:US
Practice Address - Phone:313-733-8034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302415575183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist