Provider Demographics
NPI:1972127843
Name:GHAZZAOUI, MOHAMAD HAISSAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:HAISSAM
Last Name:GHAZZAOUI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14716 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14716 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1347
Practice Address - Country:US
Practice Address - Phone:313-582-1350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303018068183700000X
MI5351016280390200000X
MI5302415557183500000X
NE9672390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program