Provider Demographics
NPI:1699294298
Name:WALI, EHSAN
Entity type:Individual
Prefix:
First Name:EHSAN
Middle Name:
Last Name:WALI
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 1:1375 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1421
Mailing Address - Country:US
Mailing Address - Phone:248-929-8174
Mailing Address - Fax:248-929-8915
Practice Address - Street 1:1375 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1421
Practice Address - Country:US
Practice Address - Phone:248-929-8174
Practice Address - Fax:248-929-8915
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302036046183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist