Provider Demographics
NPI:1720688138
Name:BERHE, MULUGETA W
Entity Type:Individual
Prefix:
First Name:MULUGETA
Middle Name:W
Last Name:BERHE
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 1:6111 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23605-1511
Mailing Address - Country:US
Mailing Address - Phone:757-637-4217
Mailing Address - Fax:757-637-4206
Practice Address - Street 1:6111 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23605-1511
Practice Address - Country:US
Practice Address - Phone:757-637-4217
Practice Address - Fax:757-637-4206
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209736183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist