Provider Demographics
NPI:1770115784
Name:MOHIDDIN, MAYA
Entity type:Individual
Prefix:
First Name:MAYA
Middle Name:
Last Name:MOHIDDIN
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 1:42215 PARKSIDE CIR APT 105
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-3349
Mailing Address - Country:US
Mailing Address - Phone:989-941-9318
Mailing Address - Fax:
Practice Address - Street 1:28800 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-2466
Practice Address - Country:US
Practice Address - Phone:586-353-1151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411859183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist