Active NPI
Dessane Komi Tomboouda
- Pharmacist
- Chicago, IL
National Provider Identifier
1356910129
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pharmacist
- License
- 051303773
- Practice address
- 11 E 75TH St
Chicago, IL 60619-1601 - Phone
- (773) 224-1211
- NPI assigned
- Jun 24, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pharmacist | 183500000X | 051303773 | IL | Primary |
Addresses
Primary practice location
11 E 75TH St
Chicago, IL 60619-1601
Mailing address
11 E 75TH St Chicago, Il
Chicago, IL 60619
Phone (773) 224-1211
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 306304197 | Medicaid | IL |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 051303773 | IL | MD | Pharmacist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1624492800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1624492800000",
"number": "1356910129",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "11 E 75TH ST CHICAGO, IL",
"city": "CHICAGO",
"state": "IL",
"postal_code": "60619",
"telephone_number": "773-224-1211"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "11 E 75TH ST",
"city": "CHICAGO",
"state": "IL",
"postal_code": "606191601",
"telephone_number": "773-224-1211"
}
],
"practiceLocations": [],
"basic": {
"last_name": "TOMBOOUDA",
"first_name": "DESSANE",
"middle_name": "KOMI",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2021-06-24",
"last_updated": "2021-06-24",
"certification_date": "2021-06-05",
"status": "A"
},
"taxonomies": [
{
"code": "183500000X",
"taxonomy_group": "193400000X SINGLE SPECIALTY GROUP",
"desc": "Pharmacist",
"state": "IL",
"license": "051303773",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "306304197",
"state": "IL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Chicago, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.