Provider Demographics
NPI:1033721121
Name:MUSTAFA, ASMAA IBRAHIM
Entity Type:Individual
Prefix:
First Name:ASMAA
Middle Name:IBRAHIM
Last Name:MUSTAFA
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 1:8700 S KEDZIE AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1024
Mailing Address - Country:US
Mailing Address - Phone:708-499-8051
Mailing Address - Fax:708-499-8076
Practice Address - Street 1:8700 S KEDZIE AVE
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-1024
Practice Address - Country:US
Practice Address - Phone:708-499-8051
Practice Address - Fax:708-499-8076
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300730183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist