=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104648666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YASMEEN ANNIE ETTRICK PHARMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2024
-----------------------------------------------------
Last Update Date | 10/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1969 W OGDEN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60612-3765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-864-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2047 GOLFVIEW CT APT 2C
-----------------------------------------------------
City | WHEATON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60189-8624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-385-5051
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 183500000X
-----------------------------------------------------
Taxonomy Name | Pharmacist
-----------------------------------------------------
License Number | 051.306426
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------