Provider Demographics
NPI:1407090996
Name:MALLUWA WADU, PRABATH PRIYANTHA (PHARM D)
Entity Type:Individual
Prefix:DR
First Name:PRABATH
Middle Name:PRIYANTHA
Last Name:MALLUWA WADU
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14A SAND FLAT RD
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9687
Mailing Address - Country:US
Mailing Address - Phone:509-422-7737
Mailing Address - Fax:
Practice Address - Street 1:617 5TH AND BENTON
Practice Address - Street 2:PO BOX C
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-422-7737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-28
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD18321183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist