Provider Demographics
NPI:1427652379
Name:MATEEN, AZRA S (RPH)
Entity type:Individual
Prefix:
First Name:AZRA
Middle Name:S
Last Name:MATEEN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 KINGSBURY RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61571-9278
Mailing Address - Country:US
Mailing Address - Phone:847-644-0725
Mailing Address - Fax:
Practice Address - Street 1:1101 PEORIA ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IL
Practice Address - Zip Code:61571-2350
Practice Address - Country:US
Practice Address - Phone:309-444-2301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-22
Last Update Date:2020-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051300285183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist