Provider Demographics
NPI:1508844911
Name:NATAWIDJAJA, ADRIAN
Entity Type:Individual
Prefix:
First Name:ADRIAN
Middle Name:
Last Name:NATAWIDJAJA
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 1:2237 N 106TH ST
Mailing Address - Street 2:APT 231
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9552
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4727 DENVER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-2316
Practice Address - Country:US
Practice Address - Phone:206-763-2626
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00057980183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist