Provider Demographics
NPI:1407441991
Name:GOBENA, AMANO N
Entity Type:Individual
Prefix:
First Name:AMANO
Middle Name:N
Last Name:GOBENA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15501 NE 12TH ST APT C341
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-4563
Mailing Address - Country:US
Mailing Address - Phone:206-766-0185
Mailing Address - Fax:
Practice Address - Street 1:7631 212TH ST SW
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7565
Practice Address - Country:US
Practice Address - Phone:425-977-4880
Practice Address - Fax:425-977-4881
Is Sole Proprietor?:No
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60647271183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist