=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245711027
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALPHA PHARM LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2018
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1260 W DEVON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-856-0944
-----------------------------------------------------
Fax | 773-856-0954
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1260 W DEVON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60660-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-856-0944
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHARMD
-----------------------------------------------------
Name | EPHREM MELESSE GEBREMEDHIN
-----------------------------------------------------
Credential | PHARMD
-----------------------------------------------------
Telephone | 773-963-1737
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 333600000X
-----------------------------------------------------
Taxonomy Name | Pharmacy
-----------------------------------------------------
License Number | 054020656
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------