Provider Demographics
NPI:1467957449
Name:HAGOS, EYOB GHEBREHIWET
Entity Type:Individual
Prefix:
First Name:EYOB
Middle Name:GHEBREHIWET
Last Name:HAGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:EYOB
Other - Middle Name:HAGOS
Other - Last Name:GHEBREHIWET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3270 DEL MONTE BLVD APT 45
Mailing Address - Street 2:
Mailing Address - City:MARINA
Mailing Address - State:CA
Mailing Address - Zip Code:93933-2430
Mailing Address - Country:US
Mailing Address - Phone:408-646-9304
Mailing Address - Fax:
Practice Address - Street 1:1055 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:SEASIDE
Practice Address - State:CA
Practice Address - Zip Code:93955-5712
Practice Address - Country:US
Practice Address - Phone:831-393-9231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA78298183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist