Provider Demographics
NPI:1083226971
Name:BISHAW, KIDIST TSEGAYE
Entity Type:Individual
Prefix:
First Name:KIDIST
Middle Name:TSEGAYE
Last Name:BISHAW
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 1:3700 HIGHWAY 365
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77642-7709
Mailing Address - Country:US
Mailing Address - Phone:409-724-1914
Mailing Address - Fax:409-724-0846
Practice Address - Street 1:3700 HIGHWAY 365
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-7709
Practice Address - Country:US
Practice Address - Phone:409-724-1914
Practice Address - Fax:409-724-0846
Is Sole Proprietor?:No
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX60487183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist