Provider Demographics
NPI:1609462985
Name:AL JAZRAWI, MARYAM
Entity Type:Individual
Prefix:
First Name:MARYAM
Middle Name:
Last Name:AL JAZRAWI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 STAUCH DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3117
Mailing Address - Country:US
Mailing Address - Phone:248-425-6620
Mailing Address - Fax:
Practice Address - Street 1:23007 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:FLAT ROCK
Practice Address - State:MI
Practice Address - Zip Code:48134-9028
Practice Address - Country:US
Practice Address - Phone:734-475-6663
Practice Address - Fax:734-675-8077
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413155183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302413155Medicaid