Provider Demographics
NPI:1023572245
Name:TEWOLDE, REZAN
Entity Type:Individual
Prefix:
First Name:REZAN
Middle Name:
Last Name:TEWOLDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37772 CHURCHILL DOWNS DRIVE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328
Mailing Address - Country:US
Mailing Address - Phone:954-397-2209
Mailing Address - Fax:
Practice Address - Street 1:37772 CHURCHILL DOWNS DRIVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328
Practice Address - Country:US
Practice Address - Phone:954-397-2209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS29695183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T430-720-54-634-0OtherDRIVING LICENSE