Provider Demographics
NPI:1790408680
Name:FEREDE, KALEAB TILAHUN (RPH)
Entity Type:Individual
Prefix:
First Name:KALEAB
Middle Name:TILAHUN
Last Name:FEREDE
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2523 ROSS RD APT 202
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-2038
Mailing Address - Country:US
Mailing Address - Phone:202-730-6675
Mailing Address - Fax:
Practice Address - Street 1:12525 PARK POTOMAC AVE
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-6942
Practice Address - Country:US
Practice Address - Phone:301-294-5333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD28792183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist