Provider Demographics
NPI:1467695510
Name:TEKELE, THOMAS T
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:T
Last Name:TEKELE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:THOMAS
Other - Middle Name:T
Other - Last Name:TEKELE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHARM D
Mailing Address - Street 1:12998 HESPERIA RD STE 102
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8317
Mailing Address - Country:US
Mailing Address - Phone:760-245-5378
Mailing Address - Fax:760-245-5738
Practice Address - Street 1:12998 HESPERIA RD
Practice Address - Street 2:STE 102
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8316
Practice Address - Country:US
Practice Address - Phone:760-245-5378
Practice Address - Fax:760-245-5738
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-18
Last Update Date:2009-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53222183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist