Provider Demographics
NPI:1194025148
Name:KIDANE -MARIAM, DAGNA E (RPH)
Entity Type:Individual
Prefix:MR
First Name:DAGNA
Middle Name:E
Last Name:KIDANE -MARIAM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11232 BRIGHT WATER WAY
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-3533
Mailing Address - Country:US
Mailing Address - Phone:661-664-4962
Mailing Address - Fax:661-663-7282
Practice Address - Street 1:11232 BRIGHT WATER WAY
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-3533
Practice Address - Country:US
Practice Address - Phone:661-664-4962
Practice Address - Fax:661-663-7282
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43171183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist