Provider Demographics
NPI:1639888340
Name:PRIDGEN, AVIONNE MAKAYLA (CPHT)
Entity Type:Individual
Prefix:
First Name:AVIONNE
Middle Name:MAKAYLA
Last Name:PRIDGEN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 S MARKET BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-3045
Mailing Address - Country:US
Mailing Address - Phone:360-748-8801
Mailing Address - Fax:360-748-1605
Practice Address - Street 1:551 S MARKET BLVD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3045
Practice Address - Country:US
Practice Address - Phone:360-748-8801
Practice Address - Fax:360-748-1605
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61315926183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician