Provider Demographics
NPI:1093098345
Name:EDAKKUNNATHU, GINOJ (PHARMD)
Entity Type:Individual
Prefix:
First Name:GINOJ
Middle Name:
Last Name:EDAKKUNNATHU
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 1:1400 E BRADY ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-1615
Mailing Address - Country:US
Mailing Address - Phone:414-272-2171
Mailing Address - Fax:
Practice Address - Street 1:1400 E BRADY ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-1615
Practice Address - Country:US
Practice Address - Phone:414-272-2171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.293353183500000X
WI15612-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist