Healthcare Provider Details

I. General information

NPI: 1760826994
Provider Name (Legal Business Name): JACOB W TESFAMARIAM PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2013
Last Update Date: 04/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 SNYDER AVE
PHILADELPHIA PA
19148-2700
US

IV. Provider business mailing address

3249 N PARK AVE
PHILADELPHIA PA
19140-5210
US

V. Phone/Fax

Practice location:
  • Phone: 215-465-3270
  • Fax:
Mailing address:
  • Phone: 646-641-0666
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP446883
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03503900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: