Provider Demographics
NPI:1659055671
Name:AHMED, EBTESAM
Entity Type:Individual
Prefix:MRS
First Name:EBTESAM
Middle Name:
Last Name:AHMED
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 1:39350 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9164
Mailing Address - Country:US
Mailing Address - Phone:248-735-6081
Mailing Address - Fax:
Practice Address - Street 1:39350 9 MILE RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-9164
Practice Address - Country:US
Practice Address - Phone:248-735-6081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302414569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist