=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154707297
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HENOK MEKONEN PHARMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/30/2015
-----------------------------------------------------
Last Update Date | 07/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4444 JACKSON ST
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303-2708
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-448-9340
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4040 PARLIAMENT DR APT 239
-----------------------------------------------------
City | ALEXANDRIA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 71303-3062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-714-4692
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | PNT. 047751
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------