Provider Demographics
NPI:1841668878
Name:MULUGETA, BISRAT
Entity type:Individual
Prefix:
First Name:BISRAT
Middle Name:
Last Name:MULUGETA
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 1:21 OVERLOOK RIDGE TER
Mailing Address - Street 2:APT 410
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-1190
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21 OVERLOOK RIDGE TER
Practice Address - Street 2:APT 410
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-1190
Practice Address - Country:US
Practice Address - Phone:717-917-6539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2015-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD22328183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist