Provider Demographics
NPI:1851692172
Name:KIDANE, MARTHA (RPH)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:KIDANE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10300 FEDERAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FEDERAL HEIGHTS
Mailing Address - State:CO
Mailing Address - Zip Code:80260-6101
Mailing Address - Country:US
Mailing Address - Phone:303-469-0809
Mailing Address - Fax:
Practice Address - Street 1:10300 FEDERAL BLVD
Practice Address - Street 2:
Practice Address - City:FEDERAL HEIGHTS
Practice Address - State:CO
Practice Address - Zip Code:80260-6101
Practice Address - Country:US
Practice Address - Phone:303-469-0809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO14842183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist