Provider Demographics
NPI:1720180672
Name:PUTRUS, IKHLAS R
Entity Type:Individual
Prefix:
First Name:IKHLAS
Middle Name:R
Last Name:PUTRUS
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 1:23100 CHERRY HILL ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1493
Mailing Address - Country:US
Mailing Address - Phone:313-274-5990
Mailing Address - Fax:313-274-1479
Practice Address - Street 1:23100 CHERRY HILL ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1493
Practice Address - Country:US
Practice Address - Phone:313-274-5990
Practice Address - Fax:313-274-1479
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302025677183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist