Provider Demographics
NPI:1952998049
Name:HUSSAINI, MIR FARAAZ
Entity Type:Individual
Prefix:
First Name:MIR
Middle Name:FARAAZ
Last Name:HUSSAINI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5423 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORTON GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60053-3452
Mailing Address - Country:US
Mailing Address - Phone:847-977-7239
Mailing Address - Fax:
Practice Address - Street 1:5423 MAIN ST
Practice Address - Street 2:
Practice Address - City:MORTON GROVE
Practice Address - State:IL
Practice Address - Zip Code:60053-3452
Practice Address - Country:US
Practice Address - Phone:847-977-7239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.302624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILNONEOtherNONE