Provider Demographics
NPI:1598322042
Name:NISSAN, BENYAMEEN
Entity Type:Individual
Prefix:
First Name:BENYAMEEN
Middle Name:
Last Name:NISSAN
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 1:42481 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42481 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-2009
Practice Address - Country:US
Practice Address - Phone:248-668-8208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist