Provider Demographics
NPI:1639824832
Name:FASIL, HIRUT (RP)
Entity Type:Individual
Prefix:
First Name:HIRUT
Middle Name:
Last Name:FASIL
Suffix:
Gender:F
Credentials:RP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 SUPERIOR ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-1945
Mailing Address - Country:US
Mailing Address - Phone:402-477-2622
Mailing Address - Fax:402-477-3751
Practice Address - Street 1:1404 SUPERIOR ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1945
Practice Address - Country:US
Practice Address - Phone:402-477-2622
Practice Address - Fax:402-477-3751
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE24113336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy