Provider Demographics
NPI:1417609181
Name:FAZAL, IFTEQUAR UDDIN
Entity Type:Individual
Prefix:MR
First Name:IFTEQUAR
Middle Name:UDDIN
Last Name:FAZAL
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 1:650 ROBINSON DR # 2
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4293
Mailing Address - Country:US
Mailing Address - Phone:248-390-5807
Mailing Address - Fax:
Practice Address - Street 1:4129 S SAGINAW ST
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2650
Practice Address - Country:US
Practice Address - Phone:248-390-5807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032237183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty