Provider Demographics
NPI:1588279038
Name:ZALZALA, MOHAMAD
Entity type:Individual
Prefix:
First Name:MOHAMAD
Middle Name:
Last Name:ZALZALA
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 1:32430 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-3227
Mailing Address - Country:US
Mailing Address - Phone:313-208-2963
Mailing Address - Fax:
Practice Address - Street 1:2200 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3058
Practice Address - Country:US
Practice Address - Phone:313-406-6979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302412926183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist