Provider Demographics
NPI:1609651454
Name:KEBEDE, MATHIAS L
Entity Type:Individual
Prefix:
First Name:MATHIAS
Middle Name:L
Last Name:KEBEDE
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 1:6003 FLANDERS ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-2452
Mailing Address - Country:US
Mailing Address - Phone:571-426-8382
Mailing Address - Fax:
Practice Address - Street 1:4515 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-2503
Practice Address - Country:US
Practice Address - Phone:703-751-4900
Practice Address - Fax:703-751-2906
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202221369183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist