Provider Demographics
NPI:1306365945
Name:MUSHTAQ, MANSOOR (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MANSOOR
Middle Name:
Last Name:MUSHTAQ
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27191 GATEWAY DR W APT 201
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4987
Mailing Address - Country:US
Mailing Address - Phone:248-991-5989
Mailing Address - Fax:
Practice Address - Street 1:75 S DEXTER ST
Practice Address - Street 2:
Practice Address - City:PINCKNEY
Practice Address - State:MI
Practice Address - Zip Code:48169-9071
Practice Address - Country:US
Practice Address - Phone:734-878-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302044240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist