Healthcare Provider Details

I. General information

NPI: 1649883406
Provider Name (Legal Business Name): AZZA ALI ABDELKARIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2020
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1713 W SPRINGFIELD AVE
CHAMPAIGN IL
61821-3011
US

IV. Provider business mailing address

413 KREBS DR
CHAMPAIGN IL
61822-1143
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-2529
  • Fax: 217-356-1423
Mailing address:
  • Phone: 217-418-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051299108
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number051299108
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: