MEDICARE: FEDAA BALLOUTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	051302641	IL

General Provider Information

NPI Number	:	1649877895
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FEDAA BALLOUTA

Provider Business Mailing Address
First Line	:	6955 HERITAGE CIR APT 1D
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60462-5158
Country	:	US
Telephone Number	:	708-733-0544
Fax Number	:

Provider Business Practice Location Address
First Line	:	3145 W 147TH ST
Second Line	:
City	:	POSEN
State	:	IL
Zip	:	60469-1438
Country	:	US
Telephone Number	:	708-385-8922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/01/2020
Last Update Date	:	10/01/2020

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Directions to “ FEDAA BALLOUTA ” Practice Location

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