Provider Demographics
NPI:1043627557
Name:KASSAYE BETRE, TSEDEY
Entity Type:Individual
Prefix:
First Name:TSEDEY
Middle Name:
Last Name:KASSAYE BETRE
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 1:11215 GEORGIA AVE APT 913
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:MD
Mailing Address - Zip Code:20902-7648
Mailing Address - Country:US
Mailing Address - Phone:213-280-9097
Mailing Address - Fax:
Practice Address - Street 1:5600 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-2927
Practice Address - Country:US
Practice Address - Phone:202-722-5252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100001642183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist