Provider Demographics
NPI:1356813000
Name:BEYDOUN, WISSAM (PHARMACISTS)
Entity Type:Individual
Prefix:MR
First Name:WISSAM
Middle Name:
Last Name:BEYDOUN
Suffix:
Gender:M
Credentials:PHARMACISTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 CENTRALIA ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3740
Mailing Address - Country:US
Mailing Address - Phone:313-663-1050
Mailing Address - Fax:
Practice Address - Street 1:13821 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2775
Practice Address - Country:US
Practice Address - Phone:248-541-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302031636183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist