Provider Demographics
NPI:1346088903
Name:ASFAW, KEBEDE
Entity type:Individual
Prefix:
First Name:KEBEDE
Middle Name:
Last Name:ASFAW
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 1:5805 ROYAL RIDGE DR UNIT L
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:22152-1021
Mailing Address - Country:US
Mailing Address - Phone:571-315-2770
Mailing Address - Fax:
Practice Address - Street 1:1680 DUKE ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-3474
Practice Address - Country:US
Practice Address - Phone:703-706-5783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202222125333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy