Healthcare Provider Details

I. General information

NPI: 1780175703
Provider Name (Legal Business Name): ATSNAF MELAKU GEBREMARIAM PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2018
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 US HIGHWAY 70 W
HAVELOCK NC
28532-9569
US

IV. Provider business mailing address

5116 WESTERN BLVD APT 915
JACKSONVILLE NC
28546-0023
US

V. Phone/Fax

Practice location:
  • Phone: 252-444-2055
  • Fax:
Mailing address:
  • Phone: 404-643-3940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number62260
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number17303
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number27589
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: