Provider Demographics
NPI:1588945067
Name:BAZZY, MOE
Entity type:Individual
Prefix:MR
First Name:MOE
Middle Name:
Last Name:BAZZY
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 1:1901 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-4513
Mailing Address - Country:US
Mailing Address - Phone:313-382-3578
Mailing Address - Fax:313-382-3853
Practice Address - Street 1:1901 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-4513
Practice Address - Country:US
Practice Address - Phone:313-382-3578
Practice Address - Fax:313-382-3853
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302032850183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist