Provider Demographics
NPI:1902267149
Name:GOMAA, AHMED
Entity type:Individual
Prefix:MR
First Name:AHMED
Middle Name:
Last Name:GOMAA
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 1:111 LAKE VILLAGE BLVD
Mailing Address - Street 2:APT 201
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1681
Mailing Address - Country:US
Mailing Address - Phone:201-675-2289
Mailing Address - Fax:
Practice Address - Street 1:25700 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-3026
Practice Address - Country:US
Practice Address - Phone:313-359-9640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302042561183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist