Provider Demographics
NPI:1407451990
Name:TESFAYE, BRUK
Entity Type:Individual
Prefix:
First Name:BRUK
Middle Name:
Last Name:TESFAYE
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 1:17021 US HIGHWAY 441
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6734
Mailing Address - Country:US
Mailing Address - Phone:352-357-6904
Mailing Address - Fax:
Practice Address - Street 1:17021 US HIGHWAY 441
Practice Address - Street 2:
Practice Address - City:MOUNT DORA
Practice Address - State:FL
Practice Address - Zip Code:32757-6734
Practice Address - Country:US
Practice Address - Phone:352-357-6904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL48626183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist