Provider Demographics
NPI:1609998087
Name:FOSMIRE RUNDGREN, ELAINE WATSON (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:WATSON
Last Name:FOSMIRE RUNDGREN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:WATSON
Other - Last Name:FOSMIRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1415 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4727 DENVER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-2316
Practice Address - Country:US
Practice Address - Phone:206-763-2626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00065427183700000X
WAPH60552395183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No183700000XPharmacy Service ProvidersPharmacy Technician