Provider Demographics
NPI:1831815554
Name:YIMER, ANTENEH
Entity type:Individual
Prefix:
First Name:ANTENEH
Middle Name:
Last Name:YIMER
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 1:5400 MACALPINE CIR APT 1138
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-5570
Mailing Address - Country:US
Mailing Address - Phone:216-313-1691
Mailing Address - Fax:
Practice Address - Street 1:9498 CHARTER GATE DR
Practice Address - Street 2:
Practice Address - City:MECHANICSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23116-5171
Practice Address - Country:US
Practice Address - Phone:804-550-4914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-14
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202218176183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist