Healthcare Provider Details

I. General information

NPI: 1154707297
Provider Name (Legal Business Name): HENOK MEKONEN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 JACKSON ST
ALEXANDRIA LA
71303-2708
US

IV. Provider business mailing address

4040 PARLIAMENT DR APT 239
ALEXANDRIA LA
71303-3062
US

V. Phone/Fax

Practice location:
  • Phone: 318-448-9340
  • Fax:
Mailing address:
  • Phone: 312-714-4692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPNT. 047751
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: