Provider Demographics
NPI:1679731509
Name:TAHBOUB, ISAM (RPH, MS)
Entity type:Individual
Prefix:
First Name:ISAM
Middle Name:
Last Name:TAHBOUB
Suffix:
Gender:M
Credentials:RPH, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5142 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507
Mailing Address - Country:US
Mailing Address - Phone:810-230-8252
Mailing Address - Fax:800-607-4925
Practice Address - Street 1:5142 MILLER RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-1042
Practice Address - Country:US
Practice Address - Phone:810-230-8252
Practice Address - Fax:800-607-4925
Is Sole Proprietor?:No
Enumeration Date:2008-05-28
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302029239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist