Provider Demographics
NPI:1750650057
Name:ZELALEM, WUDASSIE T
Entity Type:Individual
Prefix:
First Name:WUDASSIE
Middle Name:T
Last Name:ZELALEM
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 1:215 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-7243
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15100 W 87TH STREET PKWY
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66219-1420
Practice Address - Country:US
Practice Address - Phone:913-236-7271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-16
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1-14887183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist