Provider Demographics
NPI:1205560521
Name:TADESSE, BIRU S (PHARMD)
Entity type:Individual
Prefix:
First Name:BIRU
Middle Name:S
Last Name:TADESSE
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 1:31645 STATE ROUTE 20
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-3173
Mailing Address - Country:US
Mailing Address - Phone:360-679-3522
Mailing Address - Fax:360-679-2949
Practice Address - Street 1:31645 STATE ROUTE 20
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3173
Practice Address - Country:US
Practice Address - Phone:360-679-3522
Practice Address - Fax:360-679-2949
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61221786183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist