Provider Demographics
NPI:1639543630
Name:YOHANNES, EZRA
Entity Type:Individual
Prefix:DR
First Name:EZRA
Middle Name:
Last Name:YOHANNES
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 1:3115 HONEYWOOD LN
Mailing Address - Street 2:APT A
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-8875
Mailing Address - Country:US
Mailing Address - Phone:804-882-5052
Mailing Address - Fax:
Practice Address - Street 1:3533 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-2201
Practice Address - Country:US
Practice Address - Phone:540-981-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-14
Last Update Date:2015-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202214418183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist