Provider Demographics
NPI:1194588285
Name:BLUE WATER HEALTH PHARMACY
Entity type:Organization
Organization Name:BLUE WATER HEALTH PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YOUSEF
Authorized Official - Middle Name:
Authorized Official - Last Name:DABAJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-674-6559
Mailing Address - Street 1:35284 23 MILE RD STE B
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-2096
Mailing Address - Country:US
Mailing Address - Phone:313-674-6559
Mailing Address - Fax:
Practice Address - Street 1:35284 23 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-2096
Practice Address - Country:US
Practice Address - Phone:313-674-6559
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy