1144343773 NPI number — EVERGREEN PEDIATRIC CLINIC PS

Table of content: DR. HOA QUANG HUYNH PHARM.D. (NPI 1649626045)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144343773 NPI number — EVERGREEN PEDIATRIC CLINIC PS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN PEDIATRIC CLINIC PS
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:
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:
1144343773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 NE 87TH AVE
Provider Second Line Business Mailing Address:
STE 120
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98664-1989
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-892-1635
Provider Business Mailing Address Fax Number:
360-892-3146

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 NE 87TH AVE
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-1989
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-892-1635
Provider Business Practice Location Address Fax Number:
360-892-3146
Provider Enumeration Date:
04/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRYANT
Authorized Official First Name:
TERI
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
360-892-1635

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  601 115 723 , 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: 7033186 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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