Provider Demographics
NPI:1003622739
Name:WOLDEMARIAM, ENDALE GETACHEW (RPH)
Entity type:Individual
Prefix:
First Name:ENDALE
Middle Name:GETACHEW
Last Name:WOLDEMARIAM
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 1:4306 206TH ST W
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55024-8818
Mailing Address - Country:US
Mailing Address - Phone:612-532-3739
Mailing Address - Fax:
Practice Address - Street 1:2010 CLIFF RD
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-2313
Practice Address - Country:US
Practice Address - Phone:952-432-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-07
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN126754183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist