Provider Demographics
NPI:1144795063
Name:GANOOM, MAY
Entity Type:Individual
Prefix:
First Name:MAY
Middle Name:
Last Name:GANOOM
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 1:1685 BALDWIN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48340-1242
Mailing Address - Country:US
Mailing Address - Phone:248-230-2237
Mailing Address - Fax:
Practice Address - Street 1:1685 BALDWIN AVE STE 100
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-1242
Practice Address - Country:US
Practice Address - Phone:248-230-2237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-07
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033622183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist