Provider Demographics
NPI:1447871892
Name:KIDANE, YORDANOS GHEBREMICAHEAL (RPH)
Entity type:Individual
Prefix:MRS
First Name:YORDANOS
Middle Name:GHEBREMICAHEAL
Last Name:KIDANE
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15000 REGAL OAK LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-6447
Mailing Address - Country:US
Mailing Address - Phone:432-889-5081
Mailing Address - Fax:
Practice Address - Street 1:4801 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-2373
Practice Address - Country:US
Practice Address - Phone:214-388-7397
Practice Address - Fax:214-388-7397
Is Sole Proprietor?:No
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX62569183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist