Provider Demographics
NPI:1689204471
Name:ADVANCED PHYSICIAN GROUP LLC
Entity Type:Organization
Organization Name:ADVANCED PHYSICIAN GROUP LLC
Other - Org Name:HANNAHS FAITH IN HUMANITY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAZLOUM
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:734-664-1147
Mailing Address - Street 1:317 MONTESANO PARK DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-2469
Mailing Address - Country:US
Mailing Address - Phone:573-579-3360
Mailing Address - Fax:
Practice Address - Street 1:13530 MICHIGAN AVE # L2
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3574
Practice Address - Country:US
Practice Address - Phone:734-664-1147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-21
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy