Provider Demographics
NPI:1659810323
Name:BEYDOUN, JIHAD H
Entity Type:Individual
Prefix:
First Name:JIHAD
Middle Name:H
Last Name:BEYDOUN
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 1:6433 OAKMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2313
Mailing Address - Country:US
Mailing Address - Phone:313-421-3352
Mailing Address - Fax:
Practice Address - Street 1:15830 FORT ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1367
Practice Address - Country:US
Practice Address - Phone:734-282-1940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-15
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302028248183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2367616Medicaid
MI2367616Medicaid