Provider Demographics
NPI:1427931096
Name:DESTA, NEGATU B
Entity type:Individual
Prefix:
First Name:NEGATU
Middle Name:B
Last Name:DESTA
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 1:4401 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-2744
Mailing Address - Country:US
Mailing Address - Phone:317-460-9647
Mailing Address - Fax:
Practice Address - Street 1:4401 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2744
Practice Address - Country:US
Practice Address - Phone:317-460-9647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-30
Last Update Date:2025-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26031170A3336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy