Provider Demographics
NPI:1003523341
Name:FAZAL, ASNA (RPH)
Entity Type:Individual
Prefix:
First Name:ASNA
Middle Name:
Last Name:FAZAL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:687 ASTER DR
Mailing Address - Street 2:
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5336
Mailing Address - Country:US
Mailing Address - Phone:973-842-6138
Mailing Address - Fax:
Practice Address - Street 1:7501 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-1551
Practice Address - Country:US
Practice Address - Phone:847-265-9641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-04
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051305065183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist