Provider Demographics
NPI:1235863432
Name:KALJAJ, SIMON
Entity Type:Individual
Prefix:DR
First Name:SIMON
Middle Name:
Last Name:KALJAJ
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 1:2907 KRAFFT RD
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8628
Mailing Address - Country:US
Mailing Address - Phone:810-987-6346
Mailing Address - Fax:810-987-6027
Practice Address - Street 1:3813 CORKWOOD DR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-4414
Practice Address - Country:US
Practice Address - Phone:586-855-4556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413433183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist