Provider Demographics
NPI:1609417534
Name:JADEMI, KINGSLEY
Entity Type:Individual
Prefix:DR
First Name:KINGSLEY
Middle Name:
Last Name:JADEMI
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 1:16800 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3703
Mailing Address - Country:US
Mailing Address - Phone:919-300-5161
Mailing Address - Fax:
Practice Address - Street 1:16800 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3703
Practice Address - Country:US
Practice Address - Phone:919-300-5161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040406183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist