Provider Demographics
NPI:1841577384
Name:QAZZAZ, MAE (RPH)
Entity Type:Individual
Prefix:
First Name:MAE
Middle Name:
Last Name:QAZZAZ
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MISS
Other - First Name:MAE
Other - Middle Name:
Other - Last Name:QAZZAZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4800 148TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-3117
Mailing Address - Country:US
Mailing Address - Phone:708-860-8770
Mailing Address - Fax:708-687-1650
Practice Address - Street 1:4800 148TH ST
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-3117
Practice Address - Country:US
Practice Address - Phone:708-860-8770
Practice Address - Fax:708-687-1650
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051-038-416183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist