Provider Demographics
NPI:1366915035
Name:TEKLU, MESAY HAGOSE
Entity type:Individual
Prefix:MR
First Name:MESAY
Middle Name:HAGOSE
Last Name:TEKLU
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 1:1000 KEY PKWY
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4056
Mailing Address - Country:US
Mailing Address - Phone:301-624-0000
Mailing Address - Fax:
Practice Address - Street 1:1000 KEY PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4056
Practice Address - Country:US
Practice Address - Phone:301-624-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD26074183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist