Healthcare Provider Details

I. General information

NPI: 1770890865
Provider Name (Legal Business Name): BEREKET GEBRE-EGZIABHER PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2010
Last Update Date: 09/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3605 E THOMAS RD
PHOENIX AZ
85018-7505
US

IV. Provider business mailing address

3843 E POLLACK ST
PHOENIX AZ
85042-6209
US

V. Phone/Fax

Practice location:
  • Phone: 602-275-7507
  • Fax:
Mailing address:
  • Phone: 602-795-9986
  • Fax: 602-795-9986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberS013972
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: