Provider Demographics
NPI:1154639888
Name:MENGISTU, BEFKADU T (RPH)
Entity Type:Individual
Prefix:
First Name:BEFKADU
Middle Name:T
Last Name:MENGISTU
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:BEFKADU
Other - Middle Name:T
Other - Last Name:MENGISTU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPH
Mailing Address - Street 1:2738 ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19153-1820
Mailing Address - Country:US
Mailing Address - Phone:215-921-4890
Mailing Address - Fax:
Practice Address - Street 1:123 S 69TH ST
Practice Address - Street 2:
Practice Address - City:UPPER DARBY
Practice Address - State:PA
Practice Address - Zip Code:19082-3212
Practice Address - Country:US
Practice Address - Phone:610-352-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARP437550P183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist