Provider Demographics
NPI:1568605251
Name:DIERCKS, JUSTIN R (PHARMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:R
Last Name:DIERCKS
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 1:1330 ROCKEFELLER AVE
Mailing Address - Street 2:SUITE 150
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1684
Mailing Address - Country:US
Mailing Address - Phone:425-297-5220
Mailing Address - Fax:425-297-5221
Practice Address - Street 1:1330 ROCKEFELLER AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1684
Practice Address - Country:US
Practice Address - Phone:425-297-5220
Practice Address - Fax:425-297-5221
Is Sole Proprietor?:No
Enumeration Date:2009-04-11
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH602272341835P2201X, 183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care