Provider Demographics
NPI:1548538697
Name:TESFAZION, MICHAEL A (PHARM D)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:TESFAZION
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 1:724 W IRVING PARK RD
Mailing Address - Street 2:APT 2N
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-3149
Mailing Address - Country:US
Mailing Address - Phone:773-412-6885
Mailing Address - Fax:
Practice Address - Street 1:1633 W 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-1331
Practice Address - Country:US
Practice Address - Phone:773-445-9277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291883183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist