Provider Demographics
NPI:1073895975
Name:PUTHAWALA, FAZAL M (PHARMD)
Entity Type:Individual
Prefix:MR
First Name:FAZAL
Middle Name:M
Last Name:PUTHAWALA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7510 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60645-1511
Mailing Address - Country:US
Mailing Address - Phone:773-764-1765
Mailing Address - Fax:773-764-9020
Practice Address - Street 1:7510 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-1511
Practice Address - Country:US
Practice Address - Phone:773-764-1765
Practice Address - Fax:773-764-9020
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-288930183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist