Provider Demographics
NPI:1730678202
Name:ELMASRI, SARA
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:ELMASRI
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 1:1744 HIGHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1040
Mailing Address - Country:US
Mailing Address - Phone:313-522-8632
Mailing Address - Fax:
Practice Address - Street 1:220 FERRIS DR
Practice Address - Street 2:
Practice Address - City:BIG RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49307-2740
Practice Address - Country:US
Practice Address - Phone:231-591-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302043486390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302043486OtherPHARMACY INTERN LICENSE