Provider Demographics
NPI:1720461288
Name:SEBEH, IRENE DIANA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:DIANA
Last Name:SEBEH
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13196 W WAKEFIELD DR
Mailing Address - Street 2:NONE
Mailing Address - City:BEACH PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60083-3014
Mailing Address - Country:US
Mailing Address - Phone:847-249-3155
Mailing Address - Fax:
Practice Address - Street 1:3050 N LEWIS AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-2231
Practice Address - Country:US
Practice Address - Phone:847-599-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051288634183500000X
WI15376040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist