Provider Demographics
NPI:1134843220
Name:HAILE, MUSIE
Entity type:Individual
Prefix:
First Name:MUSIE
Middle Name:
Last Name:HAILE
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 1:772 FLYING SUN DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-9850
Mailing Address - Country:US
Mailing Address - Phone:804-878-3971
Mailing Address - Fax:
Practice Address - Street 1:8330 CRAWFORDSVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-1714
Practice Address - Country:US
Practice Address - Phone:317-347-4411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029554A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist