Provider Demographics
NPI:1518652122
Name:BAULEY, KENNETH (CPHT)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:BAULEY
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 SE 161ST AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-9544
Mailing Address - Country:US
Mailing Address - Phone:360-771-3817
Mailing Address - Fax:
Practice Address - Street 1:13511 SE 3RD WAY
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-6990
Practice Address - Country:US
Practice Address - Phone:360-885-0839
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61378737183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician