Provider Demographics
NPI:1093131187
Name:NIGUSSIE, DESSALEGN
Entity Type:Individual
Prefix:
First Name:DESSALEGN
Middle Name:
Last Name:NIGUSSIE
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 1:720 CHARCHLE RD
Mailing Address - Street 2:
Mailing Address - City:ADDIA ABABA
Mailing Address - State:ADDIA ABABA
Mailing Address - Zip Code:720
Mailing Address - Country:ET
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 CHARCHLE RD
Practice Address - Street 2:
Practice Address - City:ADDIA ABABA
Practice Address - State:ADDIA ABABA
Practice Address - Zip Code:720
Practice Address - Country:ET
Practice Address - Phone:301-803-8735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22138183500000X
DCPH100001673183500000X
VA0202212719183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist