Provider Demographics
NPI:1750607081
Name:NEGUSSIE, KOKOBE (PHARMACIST)
Entity type:Individual
Prefix:MS
First Name:KOKOBE
Middle Name:
Last Name:NEGUSSIE
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:CMR 411
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09112-9998
Mailing Address - Country:US
Mailing Address - Phone:490966-283-2004
Mailing Address - Fax:
Practice Address - Street 1:CMR 411
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09112-9998
Practice Address - Country:US
Practice Address - Phone:490966-283-2004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1133183500000X
MD11335183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD93122590Medicaid
MD11335Medicaid