Provider Demographics
NPI:1578286787
Name:MULETA, DESTA AYANA
Entity Type:Individual
Prefix:
First Name:DESTA
Middle Name:AYANA
Last Name:MULETA
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 1:3401 TIDWELL RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77093-7016
Mailing Address - Country:US
Mailing Address - Phone:713-691-6571
Mailing Address - Fax:713-691-5338
Practice Address - Street 1:3401 TIDWELL RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77093-7016
Practice Address - Country:US
Practice Address - Phone:713-695-6571
Practice Address - Fax:713-691-5338
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-22
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62733183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist