Provider Demographics
NPI:1932486487
Name:SOUDAGAR, JAWHARA (PHARMD)
Entity Type:Individual
Prefix:
First Name:JAWHARA
Middle Name:
Last Name:SOUDAGAR
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 1:5580 NORTHWEST HWY
Mailing Address - Street 2:T-1166
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-8016
Mailing Address - Country:US
Mailing Address - Phone:815-356-9318
Mailing Address - Fax:815-356-9318
Practice Address - Street 1:5580 NORTHWEST HWY
Practice Address - Street 2:T-1166
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8016
Practice Address - Country:US
Practice Address - Phone:815-356-9318
Practice Address - Fax:815-356-9318
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
IL051.295367183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist