Healthcare Provider Details

I. General information

NPI: 1841889573
Provider Name (Legal Business Name): MULUGETA GEBREHAWARIAT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2021
Last Update Date: 01/17/2021
Certification Date: 01/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 E CALTON RD
LAREDO TX
78041-4194
US

IV. Provider business mailing address

1019 E CALTON RD
LAREDO TX
78041-4194
US

V. Phone/Fax

Practice location:
  • Phone: 957-723-4800
  • Fax:
Mailing address:
  • Phone: 957-723-4800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number65440
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: