1952922742 NPI number — NICHOLAS ALBERT TEDJAKESUMA PHARM D

Table of content: NICHOLAS ALBERT TEDJAKESUMA PHARM D (NPI 1952922742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952922742 NPI number — NICHOLAS ALBERT TEDJAKESUMA PHARM D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEDJAKESUMA
Provider First Name:
NICHOLAS
Provider Middle Name:
ALBERT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARM D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952922742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6100 PACIFIC BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTINGTON PARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90255-2923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-826-9775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11930 STUDEBAKER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWALK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90650-7548
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-864-8138
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/03/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  82043 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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