Provider Demographics
NPI:1346515053
Name:DESALEGN, SISAY
Entity Type:Individual
Prefix:MR
First Name:SISAY
Middle Name:
Last Name:DESALEGN
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 1:802 134TH ST SW
Mailing Address - Street 2:BULDING C SUITE 140
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98204-7314
Mailing Address - Country:US
Mailing Address - Phone:800-607-6861
Mailing Address - Fax:
Practice Address - Street 1:802 134TH ST SW
Practice Address - Street 2:BULDING C SUITE 140
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98204-7314
Practice Address - Country:US
Practice Address - Phone:800-607-6861
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2012-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60001542183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist