Healthcare Provider Details

I. General information

NPI: 1316728280
Provider Name (Legal Business Name): HALEFOM GEBREMICHEAL GEBREYESUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2023
Last Update Date: 10/09/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 GERMANTOWN AVE
PHILADELPHIA PA
19144-2033
US

IV. Provider business mailing address

1310 S HARMONY ST
PHILADELPHIA PA
19146-3212
US

V. Phone/Fax

Practice location:
  • Phone: 215-713-2695
  • Fax:
Mailing address:
  • Phone: 215-789-0778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRP458075
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: