Provider Demographics
NPI:1952028391
Name:TESHOME, SAMUEL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:TESHOME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:
Other - Last Name:TESFAYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:3700 N DIXIE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5235
Mailing Address - Country:US
Mailing Address - Phone:937-275-7032
Mailing Address - Fax:
Practice Address - Street 1:3700 N DIXIE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5235
Practice Address - Country:US
Practice Address - Phone:937-275-7032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-26
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03338337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty