Provider Demographics
NPI:1659679702
Name:MANDEFRO, ALEMAYEHU LEMMA
Entity Type:Individual
Prefix:MR
First Name:ALEMAYEHU
Middle Name:LEMMA
Last Name:MANDEFRO
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 1:800 JOHN MARSHALL HWY
Mailing Address - Street 2:
Mailing Address - City:FRONT ROYAL
Mailing Address - State:VA
Mailing Address - Zip Code:22630-4577
Mailing Address - Country:US
Mailing Address - Phone:571-214-2910
Mailing Address - Fax:
Practice Address - Street 1:800 JOHN MARSHALL HWY
Practice Address - Street 2:
Practice Address - City:FRONT ROYAL
Practice Address - State:VA
Practice Address - Zip Code:22630-4577
Practice Address - Country:US
Practice Address - Phone:540-631-0332
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-13
Last Update Date:2011-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202204483183500000X
WVRP0007415183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist