Provider Demographics
NPI:1093291536
Name:SALL, ISSA (PHARMD)
Entity Type:Individual
Prefix:
First Name:ISSA
Middle Name:
Last Name:SALL
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 E WELLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2713
Mailing Address - Country:US
Mailing Address - Phone:313-850-7132
Mailing Address - Fax:
Practice Address - Street 1:3717 FENTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1554
Practice Address - Country:US
Practice Address - Phone:810-232-5118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039655183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist