Provider Demographics
NPI:1326707308
Name:SAR, KISANBREANDY ARA
Entity Type:Individual
Prefix:MR
First Name:KISANBREANDY
Middle Name:ARA
Last Name:SAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7041 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7220
Mailing Address - Country:US
Mailing Address - Phone:253-474-8500
Mailing Address - Fax:253-474-0253
Practice Address - Street 1:7041 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7220
Practice Address - Country:US
Practice Address - Phone:253-474-8500
Practice Address - Fax:253-474-0253
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61099641183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician