Provider Demographics
NPI:1508427733
Name:MEKONNEN, NEBIAT
Entity Type:Individual
Prefix:DR
First Name:NEBIAT
Middle Name:
Last Name:MEKONNEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 LINGANORE WAY
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-1962
Mailing Address - Country:US
Mailing Address - Phone:703-386-6837
Mailing Address - Fax:
Practice Address - Street 1:3623 LINGANORE WAY
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-1962
Practice Address - Country:US
Practice Address - Phone:703-386-6837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH100003633183500000X
VA0202217442183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist