Provider Demographics
NPI:1053087197
Name:KIDANU, HAFTU ADISU
Entity type:Individual
Prefix:
First Name:HAFTU
Middle Name:ADISU
Last Name:KIDANU
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 1:564 MCADAMS DR
Mailing Address - Street 2:
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344-2501
Mailing Address - Country:US
Mailing Address - Phone:937-849-1366
Mailing Address - Fax:
Practice Address - Street 1:564 MCADAMS DR
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45344-2501
Practice Address - Country:US
Practice Address - Phone:937-849-1366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03441059183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist