MEDICARE: MARTHA KIDANE RPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183500000X	Pharmacist	14842	CO

General Provider Information

NPI Number	:	1851692172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTHA KIDANE RPH

Provider Business Mailing Address
First Line	:	10300 FEDERAL BLVD
Second Line	:
City	:	FEDERAL HEIGHTS
State	:	CO
Zip	:	80260-6101
Country	:	US
Telephone Number	:	303-469-0809
Fax Number	:

Provider Business Practice Location Address
First Line	:	10300 FEDERAL BLVD
Second Line	:
City	:	FEDERAL HEIGHTS
State	:	CO
Zip	:	80260-6101
Country	:	US
Telephone Number	:	303-469-0809
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2010
Last Update Date	:	11/03/2010

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