Provider Demographics
NPI:1164707659
Name:GEBRU, MARTHA BERHANE
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:BERHANE
Last Name:GEBRU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15911 PINES BLVD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1201
Mailing Address - Country:US
Mailing Address - Phone:954-450-8896
Mailing Address - Fax:954-450-1596
Practice Address - Street 1:15911 PINES BLVD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1201
Practice Address - Country:US
Practice Address - Phone:954-450-8896
Practice Address - Fax:954-450-1596
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS39769183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist