Provider Demographics
NPI:1760013759
Name:BOU YAZBECK, MIRNA (PHARM D)
Entity Type:Individual
Prefix:
First Name:MIRNA
Middle Name:
Last Name:BOU YAZBECK
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13475 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-4214
Mailing Address - Country:US
Mailing Address - Phone:586-268-2900
Mailing Address - Fax:
Practice Address - Street 1:13475 15 MILE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48312-4214
Practice Address - Country:US
Practice Address - Phone:586-268-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302035926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist