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General NPI Number Information
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NPI Number | 1023735024
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Entity Type | Individual
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Provider Name | FASIL DEMERE TSEHAYU
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Gender | Male
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Dates
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Enumeration Date | 10/21/2022
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Last Update Date | 10/21/2022
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Provider Practice Location Address
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Address Line | 1220 N COMMERCE ST
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City | ARDMORE
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State | OK
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Zip | 73401-1806
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Country | US
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Telephone | 580-223-1041
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Fax |
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Provider Business Mailing Address
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Address Line | 3744 W BUCKINGHAM RD APT 171
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City | GARLAND
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State | TX
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Zip | 75042-4723
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Country | US
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Telephone | 469-422-5343
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 63375
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 18451
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License Number State | OK
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