Healthcare Provider Details

I. General information

NPI: 1770148843
Provider Name (Legal Business Name): TADESSE KASSIE MELESSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2019
Last Update Date: 05/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

144 SW 20TH ST
PENDLETON OR
97801-1804
US

IV. Provider business mailing address

2201 NE 112TH AVE APT J87
VANCOUVER WA
98684-4208
US

V. Phone/Fax

Practice location:
  • Phone: 541-278-5121
  • Fax:
Mailing address:
  • Phone: 202-492-5041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0017045
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: