Provider Demographics
NPI:1609820836
Name:SOUTH DEARBORN PHARMACY,INC
Entity Type:Organization
Organization Name:SOUTH DEARBORN PHARMACY,INC
Other - Org Name:SOUTH DEARBORN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:Y
Authorized Official - Last Name:HAMZEH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-841-2272
Mailing Address - Street 1:9925 DIX
Mailing Address - Street 2:SUITE # 106
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1593
Mailing Address - Country:US
Mailing Address - Phone:313-841-2272
Mailing Address - Fax:313-841-6715
Practice Address - Street 1:9925 DIX
Practice Address - Street 2:SUITE # 106
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1593
Practice Address - Country:US
Practice Address - Phone:313-841-2272
Practice Address - Fax:313-841-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010037243336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2540791Medicaid
MI0507530001Medicare NSC