Provider Demographics
NPI:1891077954
Name:DATTA, MOUMITA
Entity type:Individual
Prefix:
First Name:MOUMITA
Middle Name:
Last Name:DATTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5634 FORDHAM CIR APT 204
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3353
Mailing Address - Country:US
Mailing Address - Phone:734-981-1707
Mailing Address - Fax:
Practice Address - Street 1:14048 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3629
Practice Address - Country:US
Practice Address - Phone:313-869-2177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302039801183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist