Provider Demographics
NPI:1235531955
Name:WASSIE, TIBEBE
Entity Type:Individual
Prefix:
First Name:TIBEBE
Middle Name:
Last Name:WASSIE
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 1:5807 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97478-6961
Mailing Address - Country:US
Mailing Address - Phone:541-726-8423
Mailing Address - Fax:541-726-8473
Practice Address - Street 1:5807 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97478-6961
Practice Address - Country:US
Practice Address - Phone:541-726-8423
Practice Address - Fax:541-726-8473
Is Sole Proprietor?:No
Enumeration Date:2014-09-24
Last Update Date:2014-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0014274183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist