Provider Demographics
NPI:1346853785
Name:GEMEDA, DEREJE M
Entity Type:Individual
Prefix:
First Name:DEREJE
Middle Name:M
Last Name:GEMEDA
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 1:6525 UNIVERSITY AVE NE
Mailing Address - Street 2:
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-4331
Mailing Address - Country:US
Mailing Address - Phone:763-586-0730
Mailing Address - Fax:
Practice Address - Street 1:6525 UNIVERSITY AVE NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-4331
Practice Address - Country:US
Practice Address - Phone:763-586-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN121702183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN36-1924025Medicaid
MN361924025Medicaid