Provider Demographics
NPI:1760087399
Name:NEMARIAM, HAILE
Entity Type:Individual
Prefix:
First Name:HAILE
Middle Name:
Last Name:NEMARIAM
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 1:14900 JONES MALTSBERGER RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-3919
Mailing Address - Country:US
Mailing Address - Phone:210-496-9545
Mailing Address - Fax:
Practice Address - Street 1:14900 JONES MALTSBERGER RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-3919
Practice Address - Country:US
Practice Address - Phone:210-496-9545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX46137183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX16141550OtherCVS