=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285299693
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAIHAN SHAFI POTHIGARA PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2019
-----------------------------------------------------
Last Update Date | 05/01/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 AZALEA CIR
-----------------------------------------------------
City | STREAMWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60107-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-522-5734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 AZALEA CIR
-----------------------------------------------------
City | STREAMWOOD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60107-1847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 71844
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 298091
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------