Provider Demographics
NPI:1952922742
Name:TEDJAKESUMA, NICHOLAS ALBERT (PHARM D)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ALBERT
Last Name:TEDJAKESUMA
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 PACIFIC BLVD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2923
Mailing Address - Country:US
Mailing Address - Phone:323-826-9775
Mailing Address - Fax:
Practice Address - Street 1:11930 STUDEBAKER RD
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-7548
Practice Address - Country:US
Practice Address - Phone:562-864-8138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-03
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA82043183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist