Provider Demographics
NPI:1396473484
Name:HAILU, ABEBA G (PHARMD)
Entity type:Individual
Prefix:
First Name:ABEBA
Middle Name:G
Last Name:HAILU
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 S 500 E APT 208
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1901
Mailing Address - Country:US
Mailing Address - Phone:385-910-2562
Mailing Address - Fax:
Practice Address - Street 1:299 E PLUMB LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3449
Practice Address - Country:US
Practice Address - Phone:775-786-1884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1011001-1701183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist