Provider Demographics
NPI:1528579331
Name:SROUR, MAHMOUD
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:SROUR
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 1:5940 MIDDLESEX ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2166
Mailing Address - Country:US
Mailing Address - Phone:313-445-5656
Mailing Address - Fax:
Practice Address - Street 1:4100 WOODWARD AVE STE PHARMACY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2173
Practice Address - Country:US
Practice Address - Phone:313-832-5900
Practice Address - Fax:313-832-5901
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist