Provider Demographics
NPI:1528661030
Name:MOMANI, FIDA
Entity type:Individual
Prefix:
First Name:FIDA
Middle Name:
Last Name:MOMANI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9069
Mailing Address - Country:US
Mailing Address - Phone:849-356-4302
Mailing Address - Fax:
Practice Address - Street 1:2020 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:IL
Practice Address - Zip Code:60046-9069
Practice Address - Country:US
Practice Address - Phone:847-356-4302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295753183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist