Healthcare Provider Details

I. General information

NPI: 1073100855
Provider Name (Legal Business Name): CHIDERA C ESELE PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2020
Last Update Date: 12/28/2020
Certification Date: 12/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12751 NICOLLET AVE
BURNSVILLE MN
55337-2806
US

IV. Provider business mailing address

12231 RIVER VALLEY DR
BURNSVILLE MN
55337-1225
US

V. Phone/Fax

Practice location:
  • Phone: 952-736-8130
  • Fax:
Mailing address:
  • Phone: 952-465-9397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number122971
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: