Provider Demographics
NPI:1730638081
Name:MUDAHAR, SUKHRAJ (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:SUKHRAJ
Middle Name:
Last Name:MUDAHAR
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 FIRETHORN ST
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2001
Mailing Address - Country:US
Mailing Address - Phone:630-533-9396
Mailing Address - Fax:
Practice Address - Street 1:1901 W HARRISON ST
Practice Address - Street 2:LL-170
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3714
Practice Address - Country:US
Practice Address - Phone:630-533-9396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295390183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist