1609061969 NPI number — PEACEHEALTH

Table of content: KENNETH MUTO PHARM. D, RPH (NPI 1902297781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609061969 NPI number — PEACEHEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEACEHEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609061969
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1115 SE 164TH AVE
Provider Second Line Business Mailing Address:
DEPT 358
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98683-9324
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-729-1412
Provider Business Mailing Address Fax Number:
360-501-7555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 NE 87TH AVE
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-1965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-514-7374
Provider Business Practice Location Address Fax Number:
360-514-7384
Provider Enumeration Date:
09/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MONTALVO
Authorized Official First Name:
DARRIN
Authorized Official Middle Name:
Authorized Official Title or Position:
EVP CHIEF FINAN-GROWTH OFFICER
Authorized Official Telephone Number:
360-729-1102

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD00027022 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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