Healthcare Provider Details

I. General information

NPI: 1164020418
Provider Name (Legal Business Name): DR. ENGRIDA SAMSON MEBRAHTU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 WILLIAMSBRIDGE RD
BRONX NY
10461-6201
US

IV. Provider business mailing address

270 RIVERSIDE DR APT 11B
NEW YORK NY
10025-5221
US

V. Phone/Fax

Practice location:
  • Phone: 347-691-3922
  • Fax: 347-691-3923
Mailing address:
  • Phone: 347-886-8352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number067119
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: