Provider Demographics
NPI:1649756594
Name:ABBAS, MOHAMED TAHER
Entity Type:Individual
Prefix:
First Name:MOHAMED
Middle Name:TAHER
Last Name:ABBAS
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 1:2652 EVALINE ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3214
Mailing Address - Country:US
Mailing Address - Phone:313-452-1217
Mailing Address - Fax:
Practice Address - Street 1:5100 28TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2049
Practice Address - Country:US
Practice Address - Phone:616-233-4428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-13
Last Update Date:2018-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist