Healthcare Provider Details

I. General information

NPI: 1104648666
Provider Name (Legal Business Name): YASMEEN ANNIE ETTRICK PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1969 W OGDEN AVE
CHICAGO IL
60612-3765
US

IV. Provider business mailing address

2047 GOLFVIEW CT APT 2C
WHEATON IL
60189-8624
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 331-385-5051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051.306426
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: