Provider Demographics
NPI:1801028139
Name:WOLDEMICHAEL, TEKLU ABRAHA
Entity Type:Individual
Prefix:
First Name:TEKLU
Middle Name:ABRAHA
Last Name:WOLDEMICHAEL
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 1:300 LONG SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NC
Mailing Address - Zip Code:28704-7739
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:45 HENDERSONVILLE HWY
Practice Address - Street 2:
Practice Address - City:PISGAH FOREST
Practice Address - State:NC
Practice Address - Zip Code:28768-8895
Practice Address - Country:US
Practice Address - Phone:828-884-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20132183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0885245Medicaid