Healthcare Provider Details

I. General information

NPI: 1255616405
Provider Name (Legal Business Name): MICHAEL W GEBREKIDAN PHARMACIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1610 W 49 ST
HIALEAH FL
33012
US

IV. Provider business mailing address

12871 SW 45TH DR
MIRAMAR FL
33027-6027
US

V. Phone/Fax

Practice location:
  • Phone: 305-826-3842
  • Fax:
Mailing address:
  • Phone: 305-992-6109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS37256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: