Healthcare Provider Details

I. General information

NPI: 1184625410
Provider Name (Legal Business Name): IBTISAM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/02/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4254 W 55TH ST STE 101
CHICAGO IL
60632-4642
US

IV. Provider business mailing address

4254 W 55TH ST
CHICAGO IL
60632-4642
US

V. Phone/Fax

Practice location:
  • Phone: 773-582-2660
  • Fax: 773-767-3022
Mailing address:
  • Phone: 773-582-2660
  • Fax: 773-767-3022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUHA ABDALLAH
Title or Position: OWNER
Credential:
Phone: 773-582-2660