Provider Demographics
NPI:1376724856
Name:MIXON, TARA KELLY (PHARMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:KELLY
Last Name:MIXON
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7037 20TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-5707
Mailing Address - Country:US
Mailing Address - Phone:206-890-0150
Mailing Address - Fax:
Practice Address - Street 1:616 OLIVE WAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1717
Practice Address - Country:US
Practice Address - Phone:206-622-3565
Practice Address - Fax:206-382-9727
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-26
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00051895183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist