Provider Demographics
NPI:1215556402
Name:MAZLOUM, MOUHAMAD (PHARMD)
Entity Type:Individual
Prefix:
First Name:MOUHAMAD
Middle Name:
Last Name:MAZLOUM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26600 BRYAN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1961
Mailing Address - Country:US
Mailing Address - Phone:313-402-7112
Mailing Address - Fax:
Practice Address - Street 1:5650 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2253
Practice Address - Country:US
Practice Address - Phone:313-581-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047220183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist