Provider Demographics
NPI:1861712572
Name:WOLDETNSAE, EYOB BELAY
Entity type:Individual
Prefix:
First Name:EYOB
Middle Name:BELAY
Last Name:WOLDETNSAE
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 1:1517 REGENT MANOR CT
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904-2209
Mailing Address - Country:US
Mailing Address - Phone:240-401-0728
Mailing Address - Fax:301-622-0226
Practice Address - Street 1:1823 E WEST HWY
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20783-3032
Practice Address - Country:US
Practice Address - Phone:301-439-7100
Practice Address - Fax:301-439-7134
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17811183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist