Provider Demographics
NPI:1093921686
Name:JWAIDA, FANAR W (R PH)
Entity Type:Individual
Prefix:MRS
First Name:FANAR
Middle Name:W
Last Name:JWAIDA
Suffix:
Gender:F
Credentials:R PH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6244 PINECROFT DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2241
Mailing Address - Country:US
Mailing Address - Phone:248-865-9201
Mailing Address - Fax:248-865-9201
Practice Address - Street 1:20733 E 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4503
Practice Address - Country:US
Practice Address - Phone:586-415-4844
Practice Address - Fax:586-415-4855
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist