Provider Demographics
NPI:1376150805
Name:KUTOM, SAMAH
Entity Type:Individual
Prefix:
First Name:SAMAH
Middle Name:
Last Name:KUTOM
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 1:91 SILO RIDGE RD S
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-7336
Mailing Address - Country:US
Mailing Address - Phone:708-305-3055
Mailing Address - Fax:
Practice Address - Street 1:17955 WOLF RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-9427
Practice Address - Country:US
Practice Address - Phone:708-478-3758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051301908183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist