Provider Demographics
NPI:1285237099
Name:QATOUM, MAEN
Entity type:Individual
Prefix:
First Name:MAEN
Middle Name:
Last Name:QATOUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 W MOUND RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W MOUND RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1965
Practice Address - Country:US
Practice Address - Phone:217-875-6550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.300964183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty