Provider Demographics
NPI:1114511946
Name:KONJA, SALLY RIYADH
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:RIYADH
Last Name:KONJA
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 1:555 E GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-4611
Mailing Address - Country:US
Mailing Address - Phone:810-664-8360
Mailing Address - Fax:
Practice Address - Street 1:555 E GENESEE ST
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4611
Practice Address - Country:US
Practice Address - Phone:810-664-8360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2128150159183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist