MEDICARE: JOY EZIDINMA 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	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	PHA0015929	CO
2	1835P0018X	Pharmacist Clinician (PhC)/ Clinical Pharmacy Specialist	051.289813	IL

General Provider Information

NPI Number	:	1952732570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOY EZIDINMA PHARM.D

Provider Business Mailing Address
First Line	:	3302 W CRYSTAL ST
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60651-2375
Country	:	US
Telephone Number	:	630-418-0252
Fax Number	:

Provider Business Practice Location Address
First Line	:	3302 W CRYSTAL ST
Second Line	:	UNIT 2
City	:	CHICAGO
State	:	IL
Zip	:	60651-2375
Country	:	US
Telephone Number	:	630-418-0252
Fax Number	:

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

Provider Enumeration Date	:	12/07/2013
Last Update Date	:	12/07/2013

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