Provider Demographics
NPI:1386095180
Name:ABEBE, KALEB
Entity type:Individual
Prefix:
First Name:KALEB
Middle Name:
Last Name:ABEBE
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 1:476 TWIN BRIDGES RD APT 404
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-2130
Mailing Address - Country:US
Mailing Address - Phone:571-212-8003
Mailing Address - Fax:
Practice Address - Street 1:300 KEYSER AVE
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-5802
Practice Address - Country:US
Practice Address - Phone:318-357-0451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPST.021497183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist