Provider Demographics
NPI:1043510449
Name:LUM, JUSTIN JOHN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:JOHN
Last Name:LUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 S 56TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-5617
Mailing Address - Country:US
Mailing Address - Phone:253-471-1730
Mailing Address - Fax:
Practice Address - Street 1:707 S 56TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-5617
Practice Address - Country:US
Practice Address - Phone:253-471-1730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00059634183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist