Provider Demographics
NPI:1164020418
Name:MEBRAHTU, ENGRIDA SAMSON
Entity Type:Individual
Prefix:DR
First Name:ENGRIDA
Middle Name:SAMSON
Last Name:MEBRAHTU
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 1:270 RIVERSIDE DR APT 11B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5221
Mailing Address - Country:US
Mailing Address - Phone:347-886-8352
Mailing Address - Fax:
Practice Address - Street 1:1607 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-6201
Practice Address - Country:US
Practice Address - Phone:347-691-3922
Practice Address - Fax:347-691-3923
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0671193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy