Healthcare Provider Details

I. General information

NPI: 1174834089
Provider Name (Legal Business Name): AWET TEWOLDE GEBREGZIABHER PHARM. D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2010
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DRURY DR
LA PLATA MD
20646-5203
US

IV. Provider business mailing address

2506 QUEENS CHAPEL RD APT 302
HYATTSVILLE MD
20782-3647
US

V. Phone/Fax

Practice location:
  • Phone: 202-277-6273
  • Fax:
Mailing address:
  • Phone: 202-277-6273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberG162076789336
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: