Provider Demographics
NPI:1831503085
Name:GEBREMARIAM, HAILE
Entity type:Individual
Prefix:
First Name:HAILE
Middle Name:
Last Name:GEBREMARIAM
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 1:3095 MCMURRAY DR
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:CA
Mailing Address - Zip Code:96007-3674
Mailing Address - Country:US
Mailing Address - Phone:530-365-5753
Mailing Address - Fax:
Practice Address - Street 1:3095 MCMURRAY DR
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:CA
Practice Address - Zip Code:96007-3674
Practice Address - Country:US
Practice Address - Phone:530-365-5753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-16
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68168183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist