Provider Demographics
NPI:1477167807
Name:FARES, KHALED (RPH)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:FARES
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 1:21405 54TH PL W
Mailing Address - Street 2:
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-3023
Mailing Address - Country:US
Mailing Address - Phone:425-429-8000
Mailing Address - Fax:
Practice Address - Street 1:17524 AURORA AVE N
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98133-4813
Practice Address - Country:US
Practice Address - Phone:206-542-4964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH61053396183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist