Provider Demographics
NPI:1861098451
Name:TSEGAYE, ADDIS DEREJE
Entity type:Individual
Prefix:DR
First Name:ADDIS
Middle Name:DEREJE
Last Name:TSEGAYE
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 1:4606 KENMORE AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-1301
Mailing Address - Country:US
Mailing Address - Phone:703-370-6440
Mailing Address - Fax:
Practice Address - Street 1:4606 KENMORE AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22304-1301
Practice Address - Country:US
Practice Address - Phone:703-370-6440
Practice Address - Fax:703-212-7319
Is Sole Proprietor?:No
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202210599183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist