Provider Demographics
NPI:1457981789
Name:BEYDOUN, SOHA
Entity Type:Individual
Prefix:
First Name:SOHA
Middle Name:
Last Name:BEYDOUN
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 1:4275 FIRESTONE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2940
Mailing Address - Country:US
Mailing Address - Phone:313-801-8986
Mailing Address - Fax:
Practice Address - Street 1:23115 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2020
Practice Address - Country:US
Practice Address - Phone:313-562-7612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315104060183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist