Provider Demographics
NPI:1508326810
Name:TADESE, MUSSIE MESFEN
Entity Type:Individual
Prefix:
First Name:MUSSIE
Middle Name:MESFEN
Last Name:TADESE
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 1:2000 COCO PLUM DR APT 804
Mailing Address - Street 2:
Mailing Address - City:MARATHON
Mailing Address - State:FL
Mailing Address - Zip Code:33050-4044
Mailing Address - Country:US
Mailing Address - Phone:206-455-3782
Mailing Address - Fax:
Practice Address - Street 1:10870 OVERSEAS HWY
Practice Address - Street 2:
Practice Address - City:MARATHON
Practice Address - State:FL
Practice Address - Zip Code:33050-3455
Practice Address - Country:US
Practice Address - Phone:305-743-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS58905183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist