Provider Demographics
NPI:1053820910
Name:DOORNBOS, JEFFREY (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:DOORNBOS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26705 MAPLE VALLEY BLACK DIAMOND RD SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-8390
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26705 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8390
Practice Address - Country:US
Practice Address - Phone:425-578-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2017-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60772314183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist