Provider Demographics
NPI:1619017316
Name:BEKELE, MIMI (RPH)
Entity Type:Individual
Prefix:MS
First Name:MIMI
Middle Name:
Last Name:BEKELE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 DEBRA LU WAY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22150-7816
Mailing Address - Country:US
Mailing Address - Phone:703-622-5988
Mailing Address - Fax:
Practice Address - Street 1:6706 DEBRA LU WAY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:VA
Practice Address - Zip Code:22150-7816
Practice Address - Country:US
Practice Address - Phone:703-622-5988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011705183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist