Provider Demographics
NPI:1396151494
Name:DHALIWAL, JASWANT PAL
Entity type:Individual
Prefix:
First Name:JASWANT PAL
Middle Name:
Last Name:DHALIWAL
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 1:49136 W CENTRAL PARK
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48317-6335
Mailing Address - Country:US
Mailing Address - Phone:586-662-0366
Mailing Address - Fax:
Practice Address - Street 1:35250 S GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48035-2843
Practice Address - Country:US
Practice Address - Phone:586-791-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036947183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302036947OtherREGISTERED PHARMACIST LICENSE