Provider Demographics
NPI:1699242263
Name:GEBREMEDHIN, EPHREM MELESSE (PHARMD)
Entity type:Individual
Prefix:
First Name:EPHREM
Middle Name:MELESSE
Last Name:GEBREMEDHIN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1312
Mailing Address - Country:US
Mailing Address - Phone:773-856-0944
Mailing Address - Fax:773-856-0954
Practice Address - Street 1:1406 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1312
Practice Address - Country:US
Practice Address - Phone:773-856-0944
Practice Address - Fax:773-856-0954
Is Sole Proprietor?:No
Enumeration Date:2018-10-31
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295303183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL822456163001Medicaid