Provider Demographics
NPI:1013630854
Name:ABEDALJAWAD, MOHAMMAD
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:ABEDALJAWAD
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 1:20607 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-2646
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18600 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2257
Practice Address - Country:US
Practice Address - Phone:313-345-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302413704183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist