=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821370255
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LENA IBRAHIMIAN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2011
-----------------------------------------------------
Last Update Date | 09/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20950 GOVERNORS HWY
-----------------------------------------------------
City | OLYMPIA FIELDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60461-1039
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-747-0121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17200 POINTE DR
-----------------------------------------------------
City | ORLAND PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60467-1345
-----------------------------------------------------
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 | 288327
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------