Provider Demographics
NPI:1689176620
Name:NASSAN, MOTAZ
Entity Type:Individual
Prefix:
First Name:MOTAZ
Middle Name:
Last Name:NASSAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 S 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:PALOS HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60465-1835
Mailing Address - Country:US
Mailing Address - Phone:708-691-7779
Mailing Address - Fax:
Practice Address - Street 1:250 W 144TH ST
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2733
Practice Address - Country:US
Practice Address - Phone:708-832-2943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-06
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051301042183500000X
MI5302046325183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty