Provider Demographics
NPI:1619583887
Name:HERZ, WANNIPAT
Entity Type:Individual
Prefix:
First Name:WANNIPAT
Middle Name:
Last Name:HERZ
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 1:14427 12TH DR SE
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-1385
Mailing Address - Country:US
Mailing Address - Phone:425-346-7131
Mailing Address - Fax:
Practice Address - Street 1:14427 12TH DR SE
Practice Address - Street 2:
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-1385
Practice Address - Country:US
Practice Address - Phone:425-346-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183700000X
WAVB61081643183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVB61081643OtherPHARMACY ASSISTANT