Provider Demographics
NPI:1073720488
Name:AMARE, GIZACHEW
Entity Type:Individual
Prefix:
First Name:GIZACHEW
Middle Name:
Last Name:AMARE
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 1:2333 BORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3206
Mailing Address - Country:US
Mailing Address - Phone:805-498-6675
Mailing Address - Fax:805-498-8017
Practice Address - Street 1:2333 BORCHARD RD
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-3206
Practice Address - Country:US
Practice Address - Phone:805-498-6675
Practice Address - Fax:805-498-8017
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41311183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHA464130Medicare ID - Type Unspecified