Provider Demographics
NPI:1902941248
Name:MASISI-MMUTLE, PHADI
Entity Type:Individual
Prefix:MRS
First Name:PHADI
Middle Name:
Last Name:MASISI-MMUTLE
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 1:6514 WALTER ADAMIC LN
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-7218
Mailing Address - Country:US
Mailing Address - Phone:815-436-3463
Mailing Address - Fax:815-725-7500
Practice Address - Street 1:300 N OTTAWA ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60432-4009
Practice Address - Country:US
Practice Address - Phone:815-722-3200
Practice Address - Fax:815-725-7500
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist