Provider Demographics
NPI:1114558731
Name:MOHAMMAD, IMAD ALI (RPH)
Entity Type:Individual
Prefix:
First Name:IMAD
Middle Name:ALI
Last Name:MOHAMMAD
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 1:13580 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-3522
Mailing Address - Country:US
Mailing Address - Phone:313-653-3427
Mailing Address - Fax:313-653-3034
Practice Address - Street 1:13580 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-3522
Practice Address - Country:US
Practice Address - Phone:313-653-3427
Practice Address - Fax:313-653-3034
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315179007183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist