Provider Demographics
NPI:1346639135
Name:DOUGLAS, WESLEY (RPH)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 SR 507 SE
Mailing Address - Street 2:
Mailing Address - City:YELM
Mailing Address - State:WA
Mailing Address - Zip Code:98597-7605
Mailing Address - Country:US
Mailing Address - Phone:360-400-8062
Mailing Address - Fax:360-400-8065
Practice Address - Street 1:17100 SR 507 SE
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7605
Practice Address - Country:US
Practice Address - Phone:360-400-8062
Practice Address - Fax:360-400-8065
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00020851183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist