Provider Demographics
NPI:1477814457
Name:AYENACHEW, BEZAWIT SEYOUM
Entity Type:Individual
Prefix:
First Name:BEZAWIT
Middle Name:SEYOUM
Last Name:AYENACHEW
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 1:1836 METZEROTT ROAD
Mailing Address - Street 2:APT 527
Mailing Address - City:ADELPHI
Mailing Address - State:MD
Mailing Address - Zip Code:20783
Mailing Address - Country:US
Mailing Address - Phone:301-801-0567
Mailing Address - Fax:
Practice Address - Street 1:6130 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737-1905
Practice Address - Country:US
Practice Address - Phone:301-699-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD19909183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist