Provider Demographics
NPI:1164934782
Name:MUSTAPHA, MAHA
Entity Type:Individual
Prefix:DR
First Name:MAHA
Middle Name:
Last Name:MUSTAPHA
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 1:45711 SAMANTHA DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4016 OAKWOOD BLVD
Practice Address - Street 2:
Practice Address - City:MELVINDALE
Practice Address - State:MI
Practice Address - Zip Code:48122-1406
Practice Address - Country:US
Practice Address - Phone:313-386-8345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-05
Last Update Date:2017-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist