Provider Demographics
NPI:1477153625
Name:BAZZI, AHMAD JAMAL
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:JAMAL
Last Name:BAZZI
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 1:5956 WILLIAMSON ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2171
Mailing Address - Country:US
Mailing Address - Phone:313-485-0131
Mailing Address - Fax:
Practice Address - Street 1:63033 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2870
Practice Address - Country:US
Practice Address - Phone:586-907-7426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302048553183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist