Provider Demographics
NPI:1043526742
Name:TESFAY, KIDANE REZENE (PHARMACIST)
Entity type:Individual
Prefix:
First Name:KIDANE
Middle Name:REZENE
Last Name:TESFAY
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13765 56TH AVE S
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-4763
Mailing Address - Country:US
Mailing Address - Phone:206-694-3668
Mailing Address - Fax:
Practice Address - Street 1:9000 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98118-5017
Practice Address - Country:US
Practice Address - Phone:206-760-1076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60127454183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist