Provider Demographics
NPI:1275230476
Name:SHOKRALLA, MINA (PH61163629)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:SHOKRALLA
Suffix:
Gender:M
Credentials:PH61163629
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3220 CALIFORNIA AVE SW APT 330
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98116-3452
Mailing Address - Country:US
Mailing Address - Phone:253-260-9192
Mailing Address - Fax:
Practice Address - Street 1:2345 42ND AVE SW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-2513
Practice Address - Country:US
Practice Address - Phone:206-932-7437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61163629183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist