Provider Demographics
NPI:1275930463
Name:JALALI, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:JALALI
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 1:15100 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-4602
Mailing Address - Country:US
Mailing Address - Phone:301-776-5404
Mailing Address - Fax:
Practice Address - Street 1:15100 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-4602
Practice Address - Country:US
Practice Address - Phone:301-776-5404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD38-3714151183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist