Provider Demographics
NPI:1013673342
Name:TESFAZGHI, PHILEMON HAILE (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHILEMON
Middle Name:HAILE
Last Name:TESFAZGHI
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8935 E 21ST ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-1938
Mailing Address - Country:US
Mailing Address - Phone:317-897-6536
Mailing Address - Fax:
Practice Address - Street 1:8935 E 21ST ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-1938
Practice Address - Country:US
Practice Address - Phone:317-897-6536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029441A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist