Provider Demographics
NPI:1588349583
Name:AYYAD, GHASSAN
Entity type:Individual
Prefix:
First Name:GHASSAN
Middle Name:
Last Name:AYYAD
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 1:11390 WILLOW
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-7333
Mailing Address - Country:US
Mailing Address - Phone:313-629-4885
Mailing Address - Fax:
Practice Address - Street 1:100 EAST VIENNA ROAD
Practice Address - Street 2:
Practice Address - City:CILO
Practice Address - State:MI
Practice Address - Zip Code:48420-1421
Practice Address - Country:US
Practice Address - Phone:810-687-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302415136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist