Provider Demographics
NPI:1518684034
Name:GEBREHIWOT, SAMUEL A (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:A
Last Name:GEBREHIWOT
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11611 PRESTON RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2704
Mailing Address - Country:US
Mailing Address - Phone:234-363-1571
Mailing Address - Fax:
Practice Address - Street 1:11661 PRESTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2745
Practice Address - Country:US
Practice Address - Phone:214-363-1571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX54062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1669579157Medicaid