Provider Demographics
NPI:1376370999
Name:TADEMY, CHARLES MARCUS IV (PHARMD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARCUS
Last Name:TADEMY
Suffix:IV
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 1:1180 TYLER ST NE APT 500
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-1595
Mailing Address - Country:US
Mailing Address - Phone:701-390-8065
Mailing Address - Fax:
Practice Address - Street 1:2610 CENTRAL AVE NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-2911
Practice Address - Country:US
Practice Address - Phone:612-789-6251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126566183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist