Provider Demographics
NPI:1457948697
Name:MAWARI, SAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:SAM
Middle Name:
Last Name:MAWARI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12740 GRATIOT AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205
Mailing Address - Country:US
Mailing Address - Phone:313-458-7379
Mailing Address - Fax:313-458-7385
Practice Address - Street 1:12740 GRATIOT AVE STE 100
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205
Practice Address - Country:US
Practice Address - Phone:313-458-7379
Practice Address - Fax:313-458-7385
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-22
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412066183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist