Provider Demographics
NPI:1588025795
Name:FUENTES, GLORIA PATRICIA
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:PATRICIA
Last Name:FUENTES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 NE TENNEY RD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2831
Mailing Address - Country:US
Mailing Address - Phone:360-571-2573
Mailing Address - Fax:360-571-2567
Practice Address - Street 1:16600 SE MCGILLIVRAY BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-3419
Practice Address - Country:US
Practice Address - Phone:360-260-3333
Practice Address - Fax:360-260-3327
Is Sole Proprietor?:No
Enumeration Date:2016-03-15
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60492551183500000X
ORRPH0014256183500000X, 1835P0018X
FLPS46672183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P0018XPharmacy Service ProvidersPharmacistPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
No183500000XPharmacy Service ProvidersPharmacist