Provider Demographics
NPI:1952908873
Name:FENTA, TEGEGNE
Entity Type:Individual
Prefix:
First Name:TEGEGNE
Middle Name:
Last Name:FENTA
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 1:1606 82ND ST APT 1826
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-2683
Mailing Address - Country:US
Mailing Address - Phone:240-354-6963
Mailing Address - Fax:
Practice Address - Street 1:2304 LUBBOCK HWY
Practice Address - Street 2:
Practice Address - City:LAMESA
Practice Address - State:TX
Practice Address - Zip Code:79331-2716
Practice Address - Country:US
Practice Address - Phone:806-872-8810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1769426183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist