Provider Demographics
NPI:1619985736
Name:WATERS, ROBERT BRENT (RPH)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRENT
Last Name:WATERS
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 1:10330 MERIDIAN AVE N STE 180
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-9496
Mailing Address - Country:US
Mailing Address - Phone:206-368-6060
Mailing Address - Fax:206-368-6061
Practice Address - Street 1:1030 AVENUE D STE 2
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-2086
Practice Address - Country:US
Practice Address - Phone:360-863-3009
Practice Address - Fax:844-375-4097
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000110601835P1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P1200XPharmacy Service ProvidersPharmacistPharmacotherapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA003118OtherL&I
WA91-1996749OtherTAX ID
WA6010938Medicaid