Provider Demographics
NPI:1770148843
Name:MELESSE, TADESSE KASSIE
Entity type:Individual
Prefix:
First Name:TADESSE
Middle Name:KASSIE
Last Name:MELESSE
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 1:2201 NE 112TH AVE APT J87
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-4208
Mailing Address - Country:US
Mailing Address - Phone:202-492-5041
Mailing Address - Fax:
Practice Address - Street 1:144 SW 20TH ST
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801-1804
Practice Address - Country:US
Practice Address - Phone:541-278-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-04
Last Update Date:2019-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0017045183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist