Provider Demographics
NPI:1376957787
Name:ADMASSU, BERHANU
Entity Type:Individual
Prefix:MR
First Name:BERHANU
Middle Name:
Last Name:ADMASSU
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 1:904 WOLFE ST APT 1C
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-3680
Mailing Address - Country:US
Mailing Address - Phone:703-344-3208
Mailing Address - Fax:
Practice Address - Street 1:46965 CEDAR LAKE PLZ
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-8653
Practice Address - Country:US
Practice Address - Phone:703-430-3328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-13
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202206408183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist