Healthcare Provider Details

I. General information

NPI: 1679179089
Provider Name (Legal Business Name): HASSAN ALI KUTOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2020
Last Update Date: 12/10/2020
Certification Date: 12/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9352 W 159TH ST
ORLAND PARK IL
60462-6046
US

IV. Provider business mailing address

9352 W 159TH ST
ORLAND PARK IL
60462
US

V. Phone/Fax

Practice location:
  • Phone: 708-460-8212
  • Fax:
Mailing address:
  • Phone: 708-460-8212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.303578
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: