Provider Demographics
NPI:1801903455
Name:GHANNAM, EDWARD C (RPH)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:C
Last Name:GHANNAM
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:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48376-0609
Mailing Address - Country:US
Mailing Address - Phone:517-521-3484
Mailing Address - Fax:
Practice Address - Street 1:113 W GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:WEBBERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48892-5120
Practice Address - Country:US
Practice Address - Phone:517-521-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302027024183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5302027024OtherRPH LICENSE NUMBER