=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114688454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELTA LIF INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2022
-----------------------------------------------------
Last Update Date | 01/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7914 SYCAMORE DR
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-717-7513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7914 SYCAMORE DR
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60462-4112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-717-7513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | HAYTHAM ABDELJABER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 708-717-7513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183700000X
-----------------------------------------------------
Taxonomy Name | Pharmacy Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------