Provider Demographics
NPI:1720744634
Name:SHAMSEDEAN, SHADI (PHARMD)
Entity Type:Individual
Prefix:
First Name:SHADI
Middle Name:
Last Name:SHAMSEDEAN
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 1:24501 ROCKFORD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1332
Mailing Address - Country:US
Mailing Address - Phone:313-207-7447
Mailing Address - Fax:
Practice Address - Street 1:27901 PLYMOUTH RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2324
Practice Address - Country:US
Practice Address - Phone:248-432-7477
Practice Address - Fax:248-432-7486
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302040990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1811550536Medicaid