Provider Demographics
NPI:1265905442
Name:GEBRU, MARKOS
Entity type:Individual
Prefix:
First Name:MARKOS
Middle Name:
Last Name:GEBRU
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 1:1118 S OREGON ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3353
Mailing Address - Country:US
Mailing Address - Phone:720-285-0532
Mailing Address - Fax:
Practice Address - Street 1:1906 FORT JONES RD
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-9530
Practice Address - Country:US
Practice Address - Phone:530-842-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79899183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist