Provider Demographics
NPI:1578088969
Name:AMBAYE, MEKONEN
Entity Type:Individual
Prefix:
First Name:MEKONEN
Middle Name:
Last Name:AMBAYE
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 1:7041 MARTIN LUTHER KING JR HWY
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20785-4016
Mailing Address - Country:US
Mailing Address - Phone:301-386-6141
Mailing Address - Fax:301-386-2772
Practice Address - Street 1:7041 MARTIN LUTHER KING JR HWY
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20785-4016
Practice Address - Country:US
Practice Address - Phone:301-386-6141
Practice Address - Fax:301-386-2772
Is Sole Proprietor?:No
Enumeration Date:2017-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14041183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306944137OtherCVS