Provider Demographics
NPI:1518214527
Name:AVETISYAN, KONSTANTIN (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KONSTANTIN
Middle Name:
Last Name:AVETISYAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 VALENCIA DR
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-8198
Mailing Address - Country:US
Mailing Address - Phone:509-460-1584
Mailing Address - Fax:
Practice Address - Street 1:4215 VALENCIA DR
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-8198
Practice Address - Country:US
Practice Address - Phone:509-460-1584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-08
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60275095183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist