Provider Demographics
NPI:1124581244
Name:SABBAGH, HASAN A
Entity Type:Individual
Prefix:
First Name:HASAN
Middle Name:A
Last Name:SABBAGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3058
Mailing Address - Country:US
Mailing Address - Phone:313-970-2458
Mailing Address - Fax:313-908-9769
Practice Address - Street 1:2200 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3058
Practice Address - Country:US
Practice Address - Phone:313-970-2458
Practice Address - Fax:313-908-9769
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302044658183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302044658Medicaid