Provider Demographics
NPI:1497134373
Name:YACOUB, MINA
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:
Last Name:YACOUB
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 1:16023 51ST PL W
Mailing Address - Street 2:
Mailing Address - City:EDMONDS
Mailing Address - State:WA
Mailing Address - Zip Code:98026-4814
Mailing Address - Country:US
Mailing Address - Phone:425-345-8226
Mailing Address - Fax:
Practice Address - Street 1:1700 13TH ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1689
Practice Address - Country:US
Practice Address - Phone:425-404-4723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-25
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60573062183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist