Healthcare Provider Details

I. General information

NPI: 1033455241
Provider Name (Legal Business Name): KIDANEWOLD T GEDA PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2012
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 FORREST AVE STE 5
DOVER DE
19904-3478
US

IV. Provider business mailing address

1404 FORREST AVE STE 5
DOVER DE
19904-3478
US

V. Phone/Fax

Practice location:
  • Phone: 302-741-2273
  • Fax: 302-741-2278
Mailing address:
  • Phone: 302-741-2273
  • Fax: 302-741-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberA10003410
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: