Provider Demographics
NPI:1174661805
Name:HENRY, MICHEAL (PD)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:
Last Name:HENRY
Suffix:
Gender:M
Credentials:PD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6503 52ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-7744
Mailing Address - Country:US
Mailing Address - Phone:206-522-5784
Mailing Address - Fax:
Practice Address - Street 1:4831 35TH AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98126-2709
Practice Address - Country:US
Practice Address - Phone:206-938-6196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000203891835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric