Provider Demographics
NPI:1821530494
Name:BAZNER, ZACHARY
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:BAZNER
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 1:24841 RIVERDALE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:507 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48161-1613
Practice Address - Country:US
Practice Address - Phone:734-243-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-13
Last Update Date:2016-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302041476183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist