Idrisse B Tetsadjio, PHARMACIST

Primary specialty

PharmacistTaxonomy code 183500000X

License

031135 Issued in GA

Practice address

581 Flint River Rd
Riverdale, GA 30274-4519

Phone

(770) 603-2044

NPI assigned

Nov 23, 2020

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other names 1

• Idrisse B Tetsadjio Professional name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Georgia CVS Pharmacy L.L.C

  dba CVS Pharmacy #11017

  • Pharmacy
  • Pooler, GA
  • NPI 1578009130
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1606089600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1606089600000",
    "number": "1346844164",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "581 FLINT RIVER RD",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302744519",
            "telephone_number": "770-603-2044"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "581 FLINT RIVER RD",
            "city": "RIVERDALE",
            "state": "GA",
            "postal_code": "302744519",
            "telephone_number": "770-603-2044"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TETSADJIO",
        "first_name": "IDRISSE",
        "middle_name": "B",
        "credential": "PHARMACIST",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2020-11-23",
        "last_updated": "2020-11-23",
        "certification_date": "2020-11-23",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "183500000X",
            "taxonomy_group": "",
            "desc": "Pharmacist",
            "state": "GA",
            "license": "031135",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "IDRISSE",
            "last_name": "TETSADJIO",
            "middle_name": "B",
            "credential": "RPH",
            "code": "2",
            "type": "Professional Name"
        }
    ]
}

• Clifford Taylor II
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• The Kroger Co (Kroger Pharmacy)
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• Victoria Harris Thedford, M.D.
• Thera-Core

• Pharmacist in Riverdale, GA
• Providers in Riverdale, GA by specialty
• Pharmacist in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 23, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.