Provider Demographics
NPI:1720755523
Name:ABRAHAM, JONATHAN VARGHESE
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:VARGHESE
Last Name:ABRAHAM
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 1:5220 BUCKLEY DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6814
Mailing Address - Country:US
Mailing Address - Phone:734-218-5961
Mailing Address - Fax:
Practice Address - Street 1:51341 W HURON RIVER DR
Practice Address - Street 2:
Practice Address - City:VAN BUREN TWP
Practice Address - State:MI
Practice Address - Zip Code:48111-2571
Practice Address - Country:US
Practice Address - Phone:734-484-0482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303037902183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician