Provider Demographics
NPI:1326416314
Name:ISHAK, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:ISHAK
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 1:14500 HALL RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1229
Mailing Address - Country:US
Mailing Address - Phone:586-247-2983
Mailing Address - Fax:586-247-2983
Practice Address - Street 1:14500 HALL RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1229
Practice Address - Country:US
Practice Address - Phone:586-247-2990
Practice Address - Fax:586-247-2983
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037703183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist