Provider Demographics
NPI:1073974994
Name:ELGAWLY, MIRETTE
Entity Type:Individual
Prefix:
First Name:MIRETTE
Middle Name:
Last Name:ELGAWLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 225TH PL NE
Mailing Address - Street 2:
Mailing Address - City:SAMMAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98074-6476
Mailing Address - Country:US
Mailing Address - Phone:425-445-7903
Mailing Address - Fax:
Practice Address - Street 1:4025 DELRIDGE WAY SW STE 400
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98106-1273
Practice Address - Country:US
Practice Address - Phone:425-445-7903
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-20
Last Update Date:2016-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60569985183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist