Healthcare Provider Details

I. General information

NPI: 1619562675
Provider Name (Legal Business Name): DAWIT KIDANE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2021
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 JEFFERSON LN NE
ALBUQUERQUE NM
87109-2117
US

IV. Provider business mailing address

7004 LORETE RD NW
ALBUQUERQUE NM
87114-3458
US

V. Phone/Fax

Practice location:
  • Phone: 505-559-4495
  • Fax: 505-842-8025
Mailing address:
  • Phone: 505-610-4651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPC00000228
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: