Provider Demographics
NPI:1437661303
Name:TEKLE, BISRAT
Entity Type:Individual
Prefix:
First Name:BISRAT
Middle Name:
Last Name:TEKLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3521 W 81ST ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-1213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1076 KERN ST
Practice Address - Street 2:
Practice Address - City:TAFT
Practice Address - State:CA
Practice Address - Zip Code:93268-2743
Practice Address - Country:US
Practice Address - Phone:661-763-3132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76990183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist