Provider Demographics
NPI:1083003438
Name:DEARBORN HEIGHTS PHARMACY
Entity type:Organization
Organization Name:DEARBORN HEIGHTS PHARMACY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:MR
Authorized Official - First Name:NABIL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKIH
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:313-724-1111
Mailing Address - Street 1:25524 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-3022
Mailing Address - Country:US
Mailing Address - Phone:313-724-1111
Mailing Address - Fax:313-724-1152
Practice Address - Street 1:25524 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3022
Practice Address - Country:US
Practice Address - Phone:313-724-1111
Practice Address - Fax:313-724-1152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032051333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1649389313Medicaid