Provider Demographics
NPI:1396008017
Name:DAHLE, GAYLEN (RPH)
Entity Type:Individual
Prefix:
First Name:GAYLEN
Middle Name:
Last Name:DAHLE
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 1:4010 SE 170TH CT
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8801
Mailing Address - Country:US
Mailing Address - Phone:360-892-0036
Mailing Address - Fax:
Practice Address - Street 1:8300 NE 137TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98682-3085
Practice Address - Country:US
Practice Address - Phone:360-883-1865
Practice Address - Fax:360-883-6427
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-18
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00066350183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist