Healthcare Provider Details

I. General information

NPI: 1831815554
Provider Name (Legal Business Name): ANTENEH YIMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2022
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9498 CHARTER GATE DR
MECHANICSVILLE VA
23116-5171
US

IV. Provider business mailing address

5400 MACALPINE CIR APT 1138
GLEN ALLEN VA
23059-5570
US

V. Phone/Fax

Practice location:
  • Phone: 804-550-4914
  • Fax:
Mailing address:
  • Phone: 216-313-1691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number0202218176
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: