Provider Demographics
NPI:1205454477
Name:GAMMOH, FARIS MAZEN (PHARM D)
Entity type:Individual
Prefix:
First Name:FARIS
Middle Name:MAZEN
Last Name:GAMMOH
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35814 DEQUINDRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4290
Mailing Address - Country:US
Mailing Address - Phone:586-698-1874
Mailing Address - Fax:586-698-1875
Practice Address - Street 1:35814 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48310-4290
Practice Address - Country:US
Practice Address - Phone:586-698-1874
Practice Address - Fax:586-698-1875
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53010106493336C0003X
MI5302043431183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy