Provider Demographics
NPI:1144540758
Name:BAZZI, KHODR M (RPH)
Entity type:Individual
Prefix:MR
First Name:KHODR
Middle Name:M
Last Name:BAZZI
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WOODCREST DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1141
Mailing Address - Country:US
Mailing Address - Phone:313-414-5507
Mailing Address - Fax:
Practice Address - Street 1:181 N WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-3624
Practice Address - Country:US
Practice Address - Phone:734-589-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027084183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist