Provider Demographics
NPI:1215682836
Name:FAREA, MAHMOUD A-M
Entity type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:A-M
Last Name:FAREA
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:PO BOX 7184
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48121-7184
Mailing Address - Country:US
Mailing Address - Phone:202-600-6681
Mailing Address - Fax:
Practice Address - Street 1:21211 HARPER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2208
Practice Address - Country:US
Practice Address - Phone:586-776-7052
Practice Address - Fax:586-776-7148
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412421183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist