Provider Demographics
NPI:1801842760
Name:MUSTAPHA, HUSSAM H
Entity Type:Individual
Prefix:MR
First Name:HUSSAM
Middle Name:H
Last Name:MUSTAPHA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6635 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1812
Mailing Address - Country:US
Mailing Address - Phone:313-582-1800
Mailing Address - Fax:313-582-2894
Practice Address - Street 1:6635 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1812
Practice Address - Country:US
Practice Address - Phone:313-582-1800
Practice Address - Fax:313-582-2894
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI383430650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2358922OtherNCPDP