Healthcare Provider Details

I. General information

NPI: 1194644526
Provider Name (Legal Business Name): MUTASEM ALI AHMAD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 S COMET DR
BRAIDWOOD IL
60408-2028
US

IV. Provider business mailing address

7400 W 58TH ST
SUMMIT IL
60501-1350
US

V. Phone/Fax

Practice location:
  • Phone: 815-458-0642
  • Fax:
Mailing address:
  • Phone: 708-712-6203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051308773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: