Provider Demographics
NPI:1952855140
Name:MAHMUTOVIC, SELMIR
Entity Type:Individual
Prefix:
First Name:SELMIR
Middle Name:
Last Name:MAHMUTOVIC
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 1:28800 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1950
Mailing Address - Country:US
Mailing Address - Phone:248-304-9510
Mailing Address - Fax:248-304-9565
Practice Address - Street 1:28800 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1950
Practice Address - Country:US
Practice Address - Phone:248-304-9510
Practice Address - Fax:248-304-9565
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040782183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist