Provider Demographics
NPI:1588647267
Name:ENGSTROM, WAYNE M (RPH)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:M
Last Name:ENGSTROM
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21645 253RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-7639
Mailing Address - Country:US
Mailing Address - Phone:425-432-9174
Mailing Address - Fax:
Practice Address - Street 1:22117 SE 237TH ST
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-8533
Practice Address - Country:US
Practice Address - Phone:425-432-1234
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00007938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist