Provider Demographics
NPI:1336684943
Name:JALLOUL, FARAH
Entity Type:Individual
Prefix:
First Name:FARAH
Middle Name:
Last Name:JALLOUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6756 AMBOY ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3966
Mailing Address - Country:US
Mailing Address - Phone:313-766-3151
Mailing Address - Fax:
Practice Address - Street 1:6756 AMBOY ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3966
Practice Address - Country:US
Practice Address - Phone:313-766-3151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-05
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042011183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist