Provider Demographics
NPI:1609169861
Name:ALFONSO, MARK DAVID (PHARMD, BS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:DAVID
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:PHARMD, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3929 KITSAP WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-2451
Mailing Address - Country:US
Mailing Address - Phone:360-917-1041
Mailing Address - Fax:360-917-1047
Practice Address - Street 1:3929 KITSAP WAY
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-2451
Practice Address - Country:US
Practice Address - Phone:360-917-1041
Practice Address - Fax:360-917-1047
Is Sole Proprietor?:No
Enumeration Date:2011-05-20
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 60173831183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist