Provider Demographics
NPI:1275948390
Name:MEKONNEN, YISHAKE
Entity Type:Individual
Prefix:
First Name:YISHAKE
Middle Name:
Last Name:MEKONNEN
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 1:159 W POLK ST
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-2302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:159 W POLK ST
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-2302
Practice Address - Country:US
Practice Address - Phone:559-935-3597
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70118183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist