Provider Demographics
NPI:1740568260
Name:BAIDOUN, MOHSEN (RPH)
Entity Type:Individual
Prefix:DR
First Name:MOHSEN
Middle Name:
Last Name:BAIDOUN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23303 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2029
Mailing Address - Country:US
Mailing Address - Phone:313-974-1821
Mailing Address - Fax:
Practice Address - Street 1:23303 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2029
Practice Address - Country:US
Practice Address - Phone:313-974-1821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302037232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740568260Medicaid