Provider Demographics
NPI:1992082002
Name:AZIMZADEH, MANA (PHARMD)
Entity type:Individual
Prefix:MISS
First Name:MANA
Middle Name:
Last Name:AZIMZADEH
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 W BRIAR PL APT 6D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-4779
Mailing Address - Country:US
Mailing Address - Phone:773-325-0413
Mailing Address - Fax:773-325-2840
Practice Address - Street 1:450 W BRIAR PL
Practice Address - Street 2:APT 6D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-325-0413
Practice Address - Fax:773-325-2840
Is Sole Proprietor?:No
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.290861183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist