Provider Demographics
NPI:1497183040
Name:MIKESELL, ALLAN (RPH)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:MIKESELL
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 1:11212 SUNRISE BLVD E STE 204
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-8847
Mailing Address - Country:US
Mailing Address - Phone:253-770-3408
Mailing Address - Fax:253-770-3511
Practice Address - Street 1:11212 SUNRISE BLVD E STE 204
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8847
Practice Address - Country:US
Practice Address - Phone:253-770-3408
Practice Address - Fax:253-770-3511
Is Sole Proprietor?:No
Enumeration Date:2013-10-17
Last Update Date:2013-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00011545183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist