Provider Demographics
NPI:1477945822
Name:PETRIE, ICHIKO (PHARMD)
Entity Type:Individual
Prefix:
First Name:ICHIKO
Middle Name:
Last Name:PETRIE
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 148TH AVE NE
Mailing Address - Street 2:APT JJ-202
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-3059
Mailing Address - Country:US
Mailing Address - Phone:206-265-0987
Mailing Address - Fax:
Practice Address - Street 1:3101 WESTERN AVE
Practice Address - Street 2:#100
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-3017
Practice Address - Country:US
Practice Address - Phone:800-523-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60471627183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist