Provider Demographics
NPI:1144915703
Name:DESTA, SAMERAWIT
Entity type:Individual
Prefix:
First Name:SAMERAWIT
Middle Name:
Last Name:DESTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 OTIS PL NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20010-1701
Mailing Address - Country:US
Mailing Address - Phone:202-684-0750
Mailing Address - Fax:
Practice Address - Street 1:1050 BRENTWOOD RD NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-1000
Practice Address - Country:US
Practice Address - Phone:202-281-3901
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPH200004601183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist