Provider Demographics
NPI:1063842169
Name:MALLARI, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MALLARI
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 1:11301 SE 10TH ST APT 161
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-6129
Mailing Address - Country:US
Mailing Address - Phone:503-473-3130
Mailing Address - Fax:
Practice Address - Street 1:11301 SE 10TH ST APT 161
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-6129
Practice Address - Country:US
Practice Address - Phone:503-473-3130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60389150183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist