Provider Demographics
NPI:1386753507
Name:DIX DRUGS STORE CORP
Entity type:Organization
Organization Name:DIX DRUGS STORE CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST AND OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HASSANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FADLALLAH
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMACIST RPH
Authorized Official - Phone:313-843-2400
Mailing Address - Street 1:655 GOLFCREST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-843-2400
Mailing Address - Fax:313-843-2402
Practice Address - Street 1:10066 DIX
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1551
Practice Address - Country:US
Practice Address - Phone:313-843-2400
Practice Address - Fax:313-843-2402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2016-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5301006503183500000X, 3336C0003X
MI333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5286370001Medicare NSC
1940720Medicare UPIN