1104075589 NPI number — JANET IRENE BLACK PHARMACIST

Table of content: JANET IRENE BLACK PHARMACIST (NPI 1104075589)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104075589 NPI number — JANET IRENE BLACK PHARMACIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLACK
Provider First Name:
JANET
Provider Middle Name:
IRENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMACIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRAKEBILL
Provider Other First Name:
JANET
Provider Other Middle Name:
IRENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMACIST
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104075589
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4626 244TH PL SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ISSAQUAH
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-891-6657
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19401 40TH AVENUE WEST
Provider Second Line Business Practice Location Address:
SUITE 330 CAREER STAFF UNLIMITED
Provider Business Practice Location Address City Name:
LYNNWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-766-0122
Provider Business Practice Location Address Fax Number:
866-835-5848
Provider Enumeration Date:
09/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 183500000X , with the licence number:  PH000010498 , 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)

  • Identifier: PH00010498 . This is a "PHARMACIST LICENSE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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