Provider Demographics
NPI:1922525724
Name:ADDIS, MESSAY
Entity Type:Individual
Prefix:
First Name:MESSAY
Middle Name:
Last Name:ADDIS
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 1:1708 N UHLE ST APT 1023
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22201-3452
Mailing Address - Country:US
Mailing Address - Phone:703-371-8512
Mailing Address - Fax:
Practice Address - Street 1:3333 MASONIC DR
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3842
Practice Address - Country:US
Practice Address - Phone:318-445-6386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPTS022000183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1508871781Medicaid