Provider Demographics
NPI:1477641702
Name:PROSTAK, MORRIS (RPH)
Entity Type:Individual
Prefix:
First Name:MORRIS
Middle Name:
Last Name:PROSTAK
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26019 WOODVILLA PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4733
Mailing Address - Country:US
Mailing Address - Phone:248-569-7118
Mailing Address - Fax:
Practice Address - Street 1:8641 N TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-1425
Practice Address - Country:US
Practice Address - Phone:313-274-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302020106183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302020106OtherPHARMACY LICENSE