Provider Demographics
NPI:1285124826
Name:ABERHA, HAILE LSEDAMU
Entity type:Individual
Prefix:
First Name:HAILE
Middle Name:LSEDAMU
Last Name:ABERHA
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 1:620 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9271
Mailing Address - Country:US
Mailing Address - Phone:702-358-8463
Mailing Address - Fax:
Practice Address - Street 1:2080 NW 9TH ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-1484
Practice Address - Country:US
Practice Address - Phone:541-753-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0016599183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist