Provider Demographics
NPI:1114543550
Name:SARSAM, ISTABRAK HARITH (RPH)
Entity Type:Individual
Prefix:
First Name:ISTABRAK
Middle Name:HARITH
Last Name:SARSAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 JOHN R RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3621
Mailing Address - Country:US
Mailing Address - Phone:248-546-2872
Mailing Address - Fax:248-546-3354
Practice Address - Street 1:26800 JOHN R RD
Practice Address - Street 2:
Practice Address - City:MADISON HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48071-3621
Practice Address - Country:US
Practice Address - Phone:248-546-2872
Practice Address - Fax:248-546-3354
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76395183500000X
MI5302044686183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist