Provider Demographics
NPI:1639933708
Name:AMPONSAH, EMMANUEL
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:AMPONSAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 S LAKE PARK AVE APT 313
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60653-1564
Mailing Address - Country:US
Mailing Address - Phone:708-253-5263
Mailing Address - Fax:
Practice Address - Street 1:3500 S LAKE PARK AVE APT 313
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60653-1564
Practice Address - Country:US
Practice Address - Phone:708-253-5263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030423A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist