Provider Demographics
NPI:1831747096
Name:MODERN HEALTH PHARMACY OF BIRMINGHAM
Entity type:Organization
Organization Name:MODERN HEALTH PHARMACY OF BIRMINGHAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:
Authorized Official - Last Name:FAWAZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:313-333-3333
Mailing Address - Street 1:33722 WOODWARD AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48009-0912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33722 WOODWARD AVE STE B
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:MI
Practice Address - Zip Code:48009-0912
Practice Address - Country:US
Practice Address - Phone:313-333-3333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-30
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy