Provider Demographics
NPI:1124715230
Name:TEKLE-WOLD, SEWLANCHI DEMEKE
Entity type:Individual
Prefix:
First Name:SEWLANCHI
Middle Name:DEMEKE
Last Name:TEKLE-WOLD
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 1:425 E DUPONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-2051
Mailing Address - Country:US
Mailing Address - Phone:260-490-3447
Mailing Address - Fax:260-490-3457
Practice Address - Street 1:425 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2051
Practice Address - Country:US
Practice Address - Phone:260-490-3447
Practice Address - Fax:260-490-3457
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26029160A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist