Provider Demographics
NPI:1962534420
Name:YIMAM, FANTAHUN (PHARMD)
Entity type:Individual
Prefix:DR
First Name:FANTAHUN
Middle Name:
Last Name:YIMAM
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4605 102ND ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-7406
Mailing Address - Country:US
Mailing Address - Phone:806-798-2291
Mailing Address - Fax:806-725-0305
Practice Address - Street 1:3615 19TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1203
Practice Address - Country:US
Practice Address - Phone:806-725-0419
Practice Address - Fax:806-725-0305
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX364011835N1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835N1003XPharmacy Service ProvidersPharmacistNutrition Support