Provider Demographics
NPI:1174232722
Name:JUBRAIL, SIMON
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:JUBRAIL
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 1:215 W LAKE ST APT 3002
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-2404
Mailing Address - Country:US
Mailing Address - Phone:847-293-5474
Mailing Address - Fax:
Practice Address - Street 1:215 W LAKE ST APT 3002
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-2404
Practice Address - Country:US
Practice Address - Phone:847-293-5474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-22
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.305045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist