Provider Demographics
NPI:1649883406
Name:ABDELKARIM, AZZA ALI
Entity type:Individual
Prefix:
First Name:AZZA
Middle Name:ALI
Last Name:ABDELKARIM
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 1:413 KREBS DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-1143
Mailing Address - Country:US
Mailing Address - Phone:217-418-6963
Mailing Address - Fax:
Practice Address - Street 1:1713 W SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-3011
Practice Address - Country:US
Practice Address - Phone:217-356-2529
Practice Address - Fax:217-356-1423
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0512991081835P0018X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist