Provider Demographics
NPI:1760734727
Name:MOUKDAD, ALI (PHARMD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MOUKDAD
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4234 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3544
Mailing Address - Country:US
Mailing Address - Phone:313-971-6360
Mailing Address - Fax:
Practice Address - Street 1:4234 MAPLE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3544
Practice Address - Country:US
Practice Address - Phone:313-971-6360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040053183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302040053OtherMICHIGAN PHARMACIST LICENSE