Provider Demographics
NPI:1356950893
Name:TEKLE, KEBEBUSH (PHARMACIST)
Entity type:Individual
Prefix:DR
First Name:KEBEBUSH
Middle Name:
Last Name:TEKLE
Suffix:
Gender:F
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 N 5TH AVE APT 104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85003-4503
Mailing Address - Country:US
Mailing Address - Phone:651-243-9186
Mailing Address - Fax:
Practice Address - Street 1:4230 W MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85009-2096
Practice Address - Country:US
Practice Address - Phone:602-415-5733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZS024740183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist