Provider Demographics
NPI:1962762476
Name:ABUATIYEH, AHMAD
Entity type:Individual
Prefix:
First Name:AHMAD
Middle Name:
Last Name:ABUATIYEH
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 1:7807 SHOLER AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-1458
Mailing Address - Country:US
Mailing Address - Phone:708-822-2655
Mailing Address - Fax:
Practice Address - Street 1:7807 S. SHOLER AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455
Practice Address - Country:US
Practice Address - Phone:708-822-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2012-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051293140183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist