1144652629 NPI number — DR. ERIK DANIEL KELLISON PHARMD

Table of content: DR. ERIK DANIEL KELLISON PHARMD (NPI 1144652629)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144652629 NPI number — DR. ERIK DANIEL KELLISON PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLISON
Provider First Name:
ERIK
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
M

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:
1144652629
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 YAKIMA AVE
Provider Second Line Business Mailing Address:
SUITE 302
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-627-1244
Provider Business Mailing Address Fax Number:
253-779-6221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 YAKIMA AVE
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-627-1244
Provider Business Practice Location Address Fax Number:
253-779-6221
Provider Enumeration Date:
08/06/2013

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:  PH60389489 , 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: PH60389489 . This is a "WA STATE PHARMACIST LICENSE #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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