Provider Demographics
NPI:1982291878
Name:KHALEQ, FADE
Entity Type:Individual
Prefix:DR
First Name:FADE
Middle Name:
Last Name:KHALEQ
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 1:250 W 144TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60827-2733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 W 144TH ST
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:IL
Practice Address - Zip Code:60827-2733
Practice Address - Country:US
Practice Address - Phone:708-849-5512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-25
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051301758183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist