Individual
JOB PAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PHARMD
Contact information
Practice address
401 15TH AVE SE, PUYALLUP, WA 98372-3715
(253) 697-1885
Mailing address
321 S 47TH ST UNIT A, RENTON, WA 98055-5081
(626) 400-9880
Taxonomy
Speciality
Code
Description
License number
State
183500000X
Pharmacist
Primary
PH60874621
WA
Other
Enumeration date
03/28/2020
Last updated
03/28/2020
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