Provider Demographics
NPI:1356635122
Name:MAM, SATHANA (RPH, PHARMD)
Entity Type:Individual
Prefix:
First Name:SATHANA
Middle Name:
Last Name:MAM
Suffix:
Gender:F
Credentials:RPH, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 THREE RIVERS DR
Mailing Address - Street 2:T0628
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-3127
Mailing Address - Country:US
Mailing Address - Phone:360-578-7387
Mailing Address - Fax:
Practice Address - Street 1:205 THREE RIVERS DR
Practice Address - Street 2:T-0628
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-3127
Practice Address - Country:US
Practice Address - Phone:360-578-7387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60185564183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist