Provider Demographics
NPI:1235734112
Name:OTHMAN, FIDAH (PHARMD)
Entity Type:Individual
Prefix:
First Name:FIDAH
Middle Name:
Last Name:OTHMAN
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 1:12434 COUNTRY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-8015
Mailing Address - Country:US
Mailing Address - Phone:708-560-1101
Mailing Address - Fax:
Practice Address - Street 1:47 S LOCUST ST
Practice Address - Street 2:
Practice Address - City:MANTENO
Practice Address - State:IL
Practice Address - Zip Code:60950-1515
Practice Address - Country:US
Practice Address - Phone:815-468-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051296021183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist