Provider Demographics
NPI:1881970721
Name:BERHANU, KIDIST (PHARM D)
Entity type:Individual
Prefix:
First Name:KIDIST
Middle Name:
Last Name:BERHANU
Suffix:
Gender:F
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 TREASURE OAK CT
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-1649
Mailing Address - Country:US
Mailing Address - Phone:713-398-3491
Mailing Address - Fax:
Practice Address - Street 1:7629 RICHMOND HWY
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306-2802
Practice Address - Country:US
Practice Address - Phone:703-768-5901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-24
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202207820183500000X
TX39252183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist