Provider Demographics
NPI:1154801637
Name:KHOURY, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KHOURY
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 1:32316 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3201
Mailing Address - Country:US
Mailing Address - Phone:248-474-8290
Mailing Address - Fax:248-474-8097
Practice Address - Street 1:32316 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-3201
Practice Address - Country:US
Practice Address - Phone:248-474-8290
Practice Address - Fax:248-474-8097
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411203183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty