Healthcare Provider Details

I. General information

NPI: 1245827138
Provider Name (Legal Business Name): DR. MESGANA DEMISSIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2020
Last Update Date: 12/25/2020
Certification Date: 12/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7650 PORT CAPITAL DR
JESSUP MD
20794-6793
US

IV. Provider business mailing address

7650 PORT CAPITAL DR
JESSUP MD
20794-6793
US

V. Phone/Fax

Practice location:
  • Phone: 410-799-7770
  • Fax:
Mailing address:
  • Phone: 410-799-7770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number19468
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: