Provider Demographics
NPI:1023735024
Name:TSEHAYU, FASIL DEMERE
Entity type:Individual
Prefix:
First Name:FASIL
Middle Name:DEMERE
Last Name:TSEHAYU
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 1:3744 W BUCKINGHAM RD APT 171
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75042-4723
Mailing Address - Country:US
Mailing Address - Phone:469-422-5343
Mailing Address - Fax:
Practice Address - Street 1:1220 N COMMERCE ST
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1806
Practice Address - Country:US
Practice Address - Phone:580-223-1041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63375183500000X
OK18451183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist