Provider Demographics
NPI:1003414491
Name:DEGU, JIBAT BEKELE
Entity Type:Individual
Prefix:
First Name:JIBAT
Middle Name:BEKELE
Last Name:DEGU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 SHINGLE CREEK XING
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55430-2835
Mailing Address - Country:US
Mailing Address - Phone:612-987-6344
Mailing Address - Fax:
Practice Address - Street 1:1200 SHINGLE CREEK CROSSING
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55430
Practice Address - Country:US
Practice Address - Phone:763-354-1948
Practice Address - Fax:763-354-1942
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist