Provider Demographics
NPI:1235350125
Name:HAXHISTASA, ILDA (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ILDA
Middle Name:
Last Name:HAXHISTASA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 N LAKEVIEW AVE APT 1210
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2948
Mailing Address - Country:US
Mailing Address - Phone:847-328-9951
Mailing Address - Fax:847-328-9849
Practice Address - Street 1:2491 HOWARD ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-3638
Practice Address - Country:US
Practice Address - Phone:847-328-9951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist