Provider Demographics
NPI:1013647338
Name:TESFASELASSIE, SAMSON GOITOM
Entity Type:Individual
Prefix:
First Name:SAMSON
Middle Name:GOITOM
Last Name:TESFASELASSIE
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 1:2625 EMPIRE DR APT 5127
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-0111
Mailing Address - Country:US
Mailing Address - Phone:773-319-2437
Mailing Address - Fax:
Practice Address - Street 1:451 FM 548
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-6288
Practice Address - Country:US
Practice Address - Phone:972-552-1633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62052183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist