Provider Demographics
NPI:1376835702
Name:IREDIA, HASSANA
Entity Type:Individual
Prefix:
First Name:HASSANA
Middle Name:
Last Name:IREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9404 FAGAN CT NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 COOPER POINT RD NW
Practice Address - Street 2:SUITE 105
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4436
Practice Address - Country:US
Practice Address - Phone:360-754-8014
Practice Address - Fax:360-754-0778
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60001494183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist