Provider Demographics
NPI:1689920118
Name:NIRGUN, KANCHAN
Entity Type:Individual
Prefix:
First Name:KANCHAN
Middle Name:
Last Name:NIRGUN
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 1:31916 3RD LN SW
Mailing Address - Street 2:APT A201
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98023-4683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2401 N PEARL ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2545
Practice Address - Country:US
Practice Address - Phone:253-752-7919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60046477183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist