Healthcare Provider Details

I. General information

NPI: 1689051179
Provider Name (Legal Business Name): GIRMA BIRU HURESAE RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 COLUMBIA ST
ORLANDO FL
32805-3482
US

IV. Provider business mailing address

3615 COLUMBIA ST
ORLANDO FL
32805-3482
US

V. Phone/Fax

Practice location:
  • Phone: 407-703-8662
  • Fax: 407-703-7863
Mailing address:
  • Phone: 407-703-7862
  • Fax: 407-703-7863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS36250
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: