Healthcare Provider Details

I. General information

NPI: 1164707659
Provider Name (Legal Business Name): MRS. MARTHA BERHANE GEBRU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2011
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15911 PINES BLVD
PEMBROKE PINES FL
33027-1201
US

IV. Provider business mailing address

15911 PINES BLVD
PEMBROKE PINES FL
33027-1201
US

V. Phone/Fax

Practice location:
  • Phone: 954-450-8896
  • Fax: 954-450-1596
Mailing address:
  • Phone: 954-450-8896
  • Fax: 954-450-1596

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS39769
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: