Provider Demographics
NPI:1275139784
Name:BERHANE, HABTEAB YOHANNES
Entity Type:Individual
Prefix:
First Name:HABTEAB
Middle Name:YOHANNES
Last Name:BERHANE
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 1:2600 NORTHCOAST ST APT 35C
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-3366
Mailing Address - Country:US
Mailing Address - Phone:408-991-2880
Mailing Address - Fax:
Practice Address - Street 1:1980 SANTA ROSA AVE # 516365S
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7621
Practice Address - Country:US
Practice Address - Phone:
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83586183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist