Provider Demographics
NPI:1639637135
Name:HARATI, BASSAM
Entity Type:Individual
Prefix:
First Name:BASSAM
Middle Name:
Last Name:HARATI
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 1:14470 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2005
Mailing Address - Country:US
Mailing Address - Phone:313-340-7777
Mailing Address - Fax:313-340-4449
Practice Address - Street 1:14470 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-2005
Practice Address - Country:US
Practice Address - Phone:313-340-7777
Practice Address - Fax:313-340-4449
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53020353391835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty