Provider Demographics
NPI:1386230779
Name:BAHSOUN, GHAYATH
Entity Type:Individual
Prefix:
First Name:GHAYATH
Middle Name:
Last Name:BAHSOUN
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 1:1910 MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1330
Mailing Address - Country:US
Mailing Address - Phone:313-939-9090
Mailing Address - Fax:
Practice Address - Street 1:19851 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3247
Practice Address - Country:US
Practice Address - Phone:313-271-4050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-19
Last Update Date:2020-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist