Healthcare Provider Details

I. General information

NPI: 1699242263
Provider Name (Legal Business Name): EPHREM MELESSE GEBREMEDHIN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1406 W DEVON AVE
CHICAGO IL
60660-1312
US

IV. Provider business mailing address

1406 W DEVON AVE
CHICAGO IL
60660-1312
US

V. Phone/Fax

Practice location:
  • Phone: 773-856-0944
  • Fax: 773-856-0954
Mailing address:
  • Phone: 773-856-0944
  • Fax: 773-856-0954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051295303
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: