Provider Demographics
NPI:1578843041
Name:PATEL, MUMTAJ (PHARMD)
Entity Type:Individual
Prefix:
First Name:MUMTAJ
Middle Name:
Last Name:PATEL
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 1:21000 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1935
Mailing Address - Country:US
Mailing Address - Phone:708-898-9115
Mailing Address - Fax:
Practice Address - Street 1:21000 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461
Practice Address - Country:US
Practice Address - Phone:708-898-9115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-287219183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist