Provider Demographics
NPI:1841555422
Name:DESTA, BEHAILU ZELEKE (RPH)
Entity type:Individual
Prefix:
First Name:BEHAILU
Middle Name:ZELEKE
Last Name:DESTA
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13954 MANSARDE AVE
Mailing Address - Street 2:#272
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-6318
Mailing Address - Country:US
Mailing Address - Phone:703-677-2612
Mailing Address - Fax:703-870-7750
Practice Address - Street 1:13870 PARK CENTER RD
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-3216
Practice Address - Country:US
Practice Address - Phone:703-796-1188
Practice Address - Fax:703-796-2277
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202209123183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist