Provider Demographics
NPI:1720094410
Name:FAWAZ, WISSAM H (BS PHARM)
Entity Type:Individual
Prefix:MR
First Name:WISSAM
Middle Name:H
Last Name:FAWAZ
Suffix:
Gender:M
Credentials:BS PHARM
Other - Prefix:MR
Other - First Name:SAM
Other - Middle Name:H
Other - Last Name:FAWAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BSPHARM
Mailing Address - Street 1:1675 KINGSWAY CT
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1958
Mailing Address - Country:US
Mailing Address - Phone:734-493-3212
Mailing Address - Fax:734-238-1557
Practice Address - Street 1:1675 KINGSWAY CT
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1958
Practice Address - Country:US
Practice Address - Phone:734-493-3212
Practice Address - Fax:734-238-1557
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-07-29
Deactivation Date:2006-11-07
Deactivation Code:
Reactivation Date:2011-07-29
Provider Licenses
StateLicense IDTaxonomies
MI5302031504183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2367589OtherNABP