Provider Demographics
NPI:1790066389
Name:LAKADA, IMTIYAZ (RPH)
Entity Type:Individual
Prefix:
First Name:IMTIYAZ
Middle Name:
Last Name:LAKADA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5650 W BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60634-5301
Mailing Address - Country:US
Mailing Address - Phone:773-777-4611
Mailing Address - Fax:773-777-2303
Practice Address - Street 1:5650 W BELMONT AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60634-5301
Practice Address - Country:US
Practice Address - Phone:773-777-4611
Practice Address - Fax:773-777-2303
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051287839183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist