Provider Demographics
NPI:1285220616
Name:KIFLE, MENGISTU S (PHARM D)
Entity Type:Individual
Prefix:
First Name:MENGISTU
Middle Name:S
Last Name:KIFLE
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SILVERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-9151
Mailing Address - Country:US
Mailing Address - Phone:612-817-1198
Mailing Address - Fax:
Practice Address - Street 1:1851 BUNKER LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-4010
Practice Address - Country:US
Practice Address - Phone:763-354-5720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121462183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist