Healthcare Provider Details

I. General information

NPI: 1831627132
Provider Name (Legal Business Name): SIRAK DERESIE WOLDETSADIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 2ND ST NE
WASHINGTON DC
20002-8100
US

IV. Provider business mailing address

12924 BIG HORN DR
SILVER SPRING MD
20904-6833
US

V. Phone/Fax

Practice location:
  • Phone: 202-346-3300
  • Fax:
Mailing address:
  • Phone: 202-509-3414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P2201X
TaxonomyAmbulatory Care Pharmacist
License NumberPH100001348
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: