Provider Demographics
NPI:1295323590
Name:WUTWUT, TABARAK
Entity type:Individual
Prefix:
First Name:TABARAK
Middle Name:
Last Name:WUTWUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16100 19 MILE RD # 500
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1148
Mailing Address - Country:US
Mailing Address - Phone:586-221-4460
Mailing Address - Fax:
Practice Address - Street 1:16100 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1148
Practice Address - Country:US
Practice Address - Phone:586-221-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412287183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist