Provider Demographics
NPI:1356933873
Name:GUSTAVE, EMMANUEL (PHARMD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:
Last Name:GUSTAVE
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 1:1554 E 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60615-5550
Mailing Address - Country:US
Mailing Address - Phone:773-667-1177
Mailing Address - Fax:
Practice Address - Street 1:1554 E 55TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60615-5550
Practice Address - Country:US
Practice Address - Phone:773-667-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.303538183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist