Provider Demographics
NPI:1801412291
Name:ELHALLAK, IVANA
Entity Type:Individual
Prefix:
First Name:IVANA
Middle Name:
Last Name:ELHALLAK
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 1:12253 SYRACUSE ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-4008
Mailing Address - Country:US
Mailing Address - Phone:313-247-7913
Mailing Address - Fax:
Practice Address - Street 1:37155 HARPER AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48036-3013
Practice Address - Country:US
Practice Address - Phone:248-583-1854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302047690183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist