Provider Demographics
NPI:1952620056
Name:NEGUSE, MENGISTEAB (RPH)
Entity Type:Individual
Prefix:
First Name:MENGISTEAB
Middle Name:
Last Name:NEGUSE
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 1:421 HEATHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-5544
Mailing Address - Country:US
Mailing Address - Phone:610-449-7133
Mailing Address - Fax:
Practice Address - Street 1:2 SOUTH BROADWAY
Practice Address - Street 2:RITEAID PHARMACY
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103
Practice Address - Country:US
Practice Address - Phone:856-963-9311
Practice Address - Fax:856-964-1863
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI01829800183500000X
PARP034506T183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist