Provider Demographics
NPI:1316583602
Name:ISMAIL, HASSAN A
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:A
Last Name:ISMAIL
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 1:15301 NORMANDALE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3025
Mailing Address - Country:US
Mailing Address - Phone:313-485-0111
Mailing Address - Fax:810-214-4162
Practice Address - Street 1:15301 NORMANDALE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3025
Practice Address - Country:US
Practice Address - Phone:313-485-0111
Practice Address - Fax:810-214-4162
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-21
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029410183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist