Provider Demographics
NPI:1376833244
Name:KIDANE, TSEDAL BEYENE (RPH)
Entity Type:Individual
Prefix:
First Name:TSEDAL
Middle Name:BEYENE
Last Name:KIDANE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4906 MESA VARA ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-321-9956
Mailing Address - Fax:
Practice Address - Street 1:8101 KENSINGTON DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-0103
Practice Address - Country:US
Practice Address - Phone:704-843-7131
Practice Address - Fax:704-843-7621
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC15329183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist