Provider Demographics
NPI:1437580479
Name:NICODIMOS, WASIHUN BERHE (PHARMD, BCPS, BCMTMS)
Entity Type:Individual
Prefix:DR
First Name:WASIHUN
Middle Name:BERHE
Last Name:NICODIMOS
Suffix:
Gender:M
Credentials:PHARMD, BCPS, BCMTMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 SHEEHAN CT
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-1335
Mailing Address - Country:US
Mailing Address - Phone:505-402-7990
Mailing Address - Fax:
Practice Address - Street 1:7201 SHEEHAN CT
Practice Address - Street 2:
Practice Address - City:DERWOOD
Practice Address - State:MD
Practice Address - Zip Code:20855-1335
Practice Address - Country:US
Practice Address - Phone:505-402-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-02
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14381183500000X
MD263221835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy SpecialistGroup - Single Specialty
No183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty