Provider Demographics
NPI:1710687454
Name:MOUBARAK, ALI
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MOUBARAK
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 1:245 E WARWICK DR STE B
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1026
Mailing Address - Country:US
Mailing Address - Phone:313-598-6176
Mailing Address - Fax:
Practice Address - Street 1:245 E WARWICK DR STE B
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1026
Practice Address - Country:US
Practice Address - Phone:313-598-6176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3336C0003X, 333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy