Provider Demographics
NPI:1114045606
Name:HAILEAB, AMANUEL
Entity Type:Individual
Prefix:
First Name:AMANUEL
Middle Name:
Last Name:HAILEAB
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 1:266 KENTUCKY AVE SE # A
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2318
Mailing Address - Country:US
Mailing Address - Phone:703-629-0760
Mailing Address - Fax:
Practice Address - Street 1:6400 LANSDOWN CENTER
Practice Address - Street 2:CVS PHARMACY
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22315
Practice Address - Country:US
Practice Address - Phone:703-541-3565
Practice Address - Fax:703-339-0875
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202012981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist