Provider Demographics
NPI:1386246932
Name:WOLD, BERHANE HABTE
Entity type:Individual
Prefix:
First Name:BERHANE
Middle Name:HABTE
Last Name: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 1:13043 LEE JACKSON MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2001
Mailing Address - Country:US
Mailing Address - Phone:703-968-9293
Mailing Address - Fax:703-817-1409
Practice Address - Street 1:13043 LEE JACKSON MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-2001
Practice Address - Country:US
Practice Address - Phone:703-968-9293
Practice Address - Fax:703-817-1409
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-09
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202011650183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist