Provider Demographics
NPI:1699049080
Name:DEARBORN FRESH PHARMACY INC
Entity type:Organization
Organization Name:DEARBORN FRESH PHARMACY INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NABIL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAWILY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-455-1592
Mailing Address - Street 1:13661 COLSON ST STE A
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3232
Mailing Address - Country:US
Mailing Address - Phone:313-581-8801
Mailing Address - Fax:313-581-8802
Practice Address - Street 1:5472 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3223
Practice Address - Country:US
Practice Address - Phone:313-584-4600
Practice Address - Fax:313-584-3784
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-02
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
MI53010097743336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2133820OtherPK