Provider Demographics
NPI:1073028452
Name:WOLDETINSAE, TIGIST
Entity Type:Individual
Prefix:
First Name:TIGIST
Middle Name:
Last Name:WOLDETINSAE
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 1:1808 SALEM RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-1393
Mailing Address - Country:US
Mailing Address - Phone:757-471-1539
Mailing Address - Fax:
Practice Address - Street 1:1808 SALEM RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-1393
Practice Address - Country:US
Practice Address - Phone:757-471-1539
Practice Address - Fax:757-471-3309
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202211809183500000X
NC22906183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist