Provider Demographics
NPI:1235439845
Name:SMALL, PHILIP (PH 00009516)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:SMALL
Suffix:
Gender:M
Credentials:PH 00009516
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 SE VALLEY VIEW WAY
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-4300
Mailing Address - Country:US
Mailing Address - Phone:360-748-1987
Mailing Address - Fax:360-740-8985
Practice Address - Street 1:1100 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3428
Practice Address - Country:US
Practice Address - Phone:360-740-6750
Practice Address - Fax:360-740-8985
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 00009516183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist