Healthcare Provider Details

I. General information

NPI: 1568951945
Provider Name (Legal Business Name): ABEBAW DEJENE TADESSE PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2018
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W PIERCE ST
CARLSBAD NM
88220-4024
US

IV. Provider business mailing address

609 N ALAMEDA ST APT 6
CARLSBAD NM
88220-5026
US

V. Phone/Fax

Practice location:
  • Phone: 575-887-0572
  • Fax:
Mailing address:
  • Phone: 720-277-7325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP.00008869
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: