Provider Demographics
NPI:1154148393
Name:MIZUREE, SHELAN KHALID
Entity type:Individual
Prefix:
First Name:SHELAN
Middle Name:KHALID
Last Name:MIZUREE
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 1:5113 HICKORY POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6812
Mailing Address - Country:US
Mailing Address - Phone:734-678-9165
Mailing Address - Fax:
Practice Address - Street 1:27435 FORD RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2920
Practice Address - Country:US
Practice Address - Phone:734-513-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302415853183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist