Healthcare Provider Details

I. General information

NPI: 1376150805
Provider Name (Legal Business Name): SAMAH KUTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2020
Last Update Date: 09/29/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17955 WOLF RD
ORLAND PARK IL
60467-9427
US

IV. Provider business mailing address

91 SILO RIDGE RD S
ORLAND PARK IL
60467-7336
US

V. Phone/Fax

Practice location:
  • Phone: 708-478-3758
  • Fax:
Mailing address:
  • Phone: 708-305-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051301908
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: