Provider Demographics
NPI:1487242806
Name:JADALLAH, DENA
Entity type:Individual
Prefix:
First Name:DENA
Middle Name:
Last Name:JADALLAH
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 1:20054 DOVETAIL DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1182
Mailing Address - Country:US
Mailing Address - Phone:313-523-1990
Mailing Address - Fax:
Practice Address - Street 1:5709 S TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48125-2025
Practice Address - Country:US
Practice Address - Phone:313-292-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-03
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI53024131563336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy