Provider Demographics
NPI:1386628634
Name:BAGBY, MICHAEL THEODORE (RPH)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THEODORE
Last Name:BAGBY
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 1:19150 NE WOODINVILLE DUVALL RD
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98077-9477
Mailing Address - Country:US
Mailing Address - Phone:425-788-6658
Mailing Address - Fax:
Practice Address - Street 1:19150 NE WOODINVILLE DUVALL RD
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98077-9477
Practice Address - Country:US
Practice Address - Phone:425-788-6658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH19152183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist