Provider Demographics
NPI:1639707482
Name:PAN, JOB (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOB
Middle Name:
Last Name:PAN
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 S 47TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5081
Mailing Address - Country:US
Mailing Address - Phone:626-400-9880
Mailing Address - Fax:
Practice Address - Street 1:401 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3715
Practice Address - Country:US
Practice Address - Phone:253-697-1885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60874621183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist