Provider Demographics
NPI:1811006794
Name:FADLALLAH, SUSAN
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:
Last Name:FADLALLAH
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 1:20526 PLYMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228-1201
Mailing Address - Country:US
Mailing Address - Phone:313-838-2555
Mailing Address - Fax:313-838-1320
Practice Address - Street 1:20526 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1201
Practice Address - Country:US
Practice Address - Phone:313-838-2555
Practice Address - Fax:313-838-1320
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI025932183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0988300001Medicare NSC