Provider Demographics
NPI:1679151336
Name:EGHTESAD, SIMA
Entity type:Individual
Prefix:
First Name:SIMA
Middle Name:
Last Name:EGHTESAD
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 1:14120 CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60418-2153
Mailing Address - Country:US
Mailing Address - Phone:708-371-9900
Mailing Address - Fax:708-371-9901
Practice Address - Street 1:14120 CICERO AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60418-2153
Practice Address - Country:US
Practice Address - Phone:708-371-9900
Practice Address - Fax:708-371-9901
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289936183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist