Provider Demographics
NPI:1457835779
Name:DAKROUB, HASSAN
Entity Type:Individual
Prefix:
First Name:HASSAN
Middle Name:
Last Name:DAKROUB
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 1:1624 N VERNON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-2504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1765 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-1901
Practice Address - Country:US
Practice Address - Phone:313-928-8638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2022-06-14
Deactivation Date:2019-10-09
Deactivation Code:
Reactivation Date:2022-06-14
Provider Licenses
StateLicense IDTaxonomies
MI5302044388183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist