Provider Demographics
NPI:1821757402
Name:AKALU, TINA ENGIDAW
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:ENGIDAW
Last Name:AKALU
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 1:3755 LOCKLAND DR APT 1
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-3567
Mailing Address - Country:US
Mailing Address - Phone:310-948-6768
Mailing Address - Fax:
Practice Address - Street 1:12511 MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-2305
Practice Address - Country:US
Practice Address - Phone:818-506-8795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-10
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA85511183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist