Healthcare Provider Details

I. General information

NPI: 1831532647
Provider Name (Legal Business Name): IAN GYAMFI SARPONG PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: IAN GYAMFI SARPONG PHARMD

II. Dates (important events)

Enumeration Date: 04/10/2013
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 W ROOSEVELT RD
CHICAGO IL
60624-4339
US

IV. Provider business mailing address

3401 W ROOSEVELT RD
CHICAGO IL
60624-4339
US

V. Phone/Fax

Practice location:
  • Phone: 773-542-1232
  • Fax:
Mailing address:
  • Phone: 773-542-1232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number049176170
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number45017363A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number051-299428
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: