MEDICARE: DR. IHEANYI SAMUEL UFOMBA PHARM. D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	IL051289472	IL

General Provider Information

NPI Number	:	1871870790
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IHEANYI SAMUEL UFOMBA PHARM. D

Provider Business Mailing Address
First Line	:	4709 ABBEY LN
Second Line	:
City	:	MATTESON
State	:	IL
Zip	:	60443-1894
Country	:	US
Telephone Number	:	708-747-1678
Fax Number	:

Provider Business Practice Location Address
First Line	:	6330 S KING DR
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-3115
Country	:	US
Telephone Number	:	773-324-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/06/2011
Last Update Date	:	11/06/2011

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