Provider Demographics
NPI:1619562675
Name:KIDANE, DAWIT (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:DAWIT
Middle Name:
Last Name:KIDANE
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7004 LORETE RD NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-3458
Mailing Address - Country:US
Mailing Address - Phone:505-610-4651
Mailing Address - Fax:
Practice Address - Street 1:4610 JEFFERSON LN NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-2117
Practice Address - Country:US
Practice Address - Phone:505-559-4495
Practice Address - Fax:505-842-8025
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPC000002281835P0018X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist