Healthcare Provider Details

I. General information

NPI: 1174213342
Provider Name (Legal Business Name): MOUTAZ HEMAIDAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2023
Last Update Date: 05/11/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9443 S 81ST CT
HICKORY HILLS IL
60457-1907
US

IV. Provider business mailing address

9443 S 81ST CT
HICKORY HILLS IL
60457-1907
US

V. Phone/Fax

Practice location:
  • Phone: 708-543-5594
  • Fax:
Mailing address:
  • Phone: 708-543-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051292955
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: