Provider Demographics
NPI:1760874697
Name:ABEBE, MISMAK (PHARMD)
Entity Type:Individual
Prefix:
First Name:MISMAK
Middle Name:
Last Name:ABEBE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1214
Mailing Address - Country:US
Mailing Address - Phone:203-322-7669
Mailing Address - Fax:203-322-9465
Practice Address - Street 1:1203 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1214
Practice Address - Country:US
Practice Address - Phone:203-322-7669
Practice Address - Fax:203-322-9465
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCT.0013090183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist