Provider Demographics
NPI:1619468469
Name:MAMO, MESKEREM
Entity Type:Individual
Prefix:
First Name:MESKEREM
Middle Name:
Last Name:MAMO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 GLENN CLUB DR APT 922
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3471
Mailing Address - Country:US
Mailing Address - Phone:615-424-9841
Mailing Address - Fax:
Practice Address - Street 1:2586 LAWRENCEVILLE HWY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-3229
Practice Address - Country:US
Practice Address - Phone:770-491-8616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-27
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN39971183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist