Provider Demographics
NPI:1093045460
Name:DEMESSE, KIDEST-MIMI AGONAFER (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KIDEST-MIMI
Middle Name:AGONAFER
Last Name:DEMESSE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 S LANCASTER RD # 119
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-7167
Mailing Address - Country:US
Mailing Address - Phone:214-742-8387
Mailing Address - Fax:214-857-0585
Practice Address - Street 1:4500 S LANCASTER RD # 119
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-742-8387
Practice Address - Fax:214-857-0585
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX48265183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist