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General NPI Number Information
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NPI Number | 1437420460
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Entity Type | Organization
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Legal Business Name | AVICENNA PHARMACY INC
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Dates
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Enumeration Date | 01/23/2012
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Last Update Date | 08/30/2023
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Provider Practice Location Address
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Address Line | 10837 S CICERO AVE STE 110C
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City | OAK LAWN
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State | IL
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Zip | 60453-6459
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Country | US
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Telephone | 708-529-7222
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Fax | 708-529-7325
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Provider Business Mailing Address
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Address Line | 10604 SOUTHWEST HWY STE 102
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City | CHICAGO RIDGE
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State | IL
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Zip | 60415-2704
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Country | US
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Telephone | 708-930-5393
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Fax | 708-529-3593
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Authorized Official
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Title or Position | OWNER, PIC, AO
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Name | AHMED MAHAFZAH
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Credential | RPH
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Telephone | 708-529-7222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0004X
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Taxonomy Name | Compounding Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 054017745
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License Number State | IL
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