Provider Demographics
NPI:1124375506
Name:MACE, PHIL (PHARMD)
Entity Type:Individual
Prefix:
First Name:PHIL
Middle Name:
Last Name:MACE
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 1:3184 OCEAN BEACH HWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-4378
Mailing Address - Country:US
Mailing Address - Phone:360-425-6222
Mailing Address - Fax:360-636-6731
Practice Address - Street 1:3184 OCEAN BEACH HWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4378
Practice Address - Country:US
Practice Address - Phone:360-425-6222
Practice Address - Fax:360-636-6731
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-05
Last Update Date:2012-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60284334183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist