Provider Demographics
NPI:1881263929
Name:HAIDARDIAB, IMAD
Entity type:Individual
Prefix:
First Name:IMAD
Middle Name:
Last Name:HAIDARDIAB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 PELHAM ST STE 3
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3852
Mailing Address - Country:US
Mailing Address - Phone:313-565-2745
Mailing Address - Fax:
Practice Address - Street 1:3815 PELHAM ST STE 3
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3852
Practice Address - Country:US
Practice Address - Phone:313-565-2745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302033891183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist