Provider Demographics
NPI:1699370544
Name:TANNA, POONAM (PHARMD)
Entity Type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:TANNA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S WELLS ST APT 2501
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4643
Mailing Address - Country:US
Mailing Address - Phone:708-205-6048
Mailing Address - Fax:
Practice Address - Street 1:205 N COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7801
Practice Address - Country:US
Practice Address - Phone:312-861-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051295113183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist