Provider Demographics
NPI:1134725393
Name:WOLDEMARIAM, AHADU (PHARMD)
Entity type:Individual
Prefix:
First Name:AHADU
Middle Name:
Last Name:WOLDEMARIAM
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 1:301 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-1649
Mailing Address - Country:US
Mailing Address - Phone:617-524-2419
Mailing Address - Fax:844-411-6218
Practice Address - Street 1:301 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-1649
Practice Address - Country:US
Practice Address - Phone:617-524-2419
Practice Address - Fax:844-411-6218
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA26496183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist