Provider Demographics
NPI:1083017016
Name:HANSEN, MARK (PHARMACIST)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:HANSEN
Suffix:
Gender:M
Credentials:PHARMACIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 164TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98087-8515
Mailing Address - Country:US
Mailing Address - Phone:425-741-3646
Mailing Address - Fax:
Practice Address - Street 1:1400 164TH ST SW
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98087-8515
Practice Address - Country:US
Practice Address - Phone:425-741-3646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00010185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist