Provider Demographics
NPI:1336616176
Name:AZZOUZ, ANGELA
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:AZZOUZ
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 1:29805 LILLEY TRL
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-1823
Mailing Address - Country:US
Mailing Address - Phone:248-767-9968
Mailing Address - Fax:
Practice Address - Street 1:47300 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-2551
Practice Address - Country:US
Practice Address - Phone:248-960-0352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302045673183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI183500000XMedicaid