Provider Demographics
NPI:1720392855
Name:YOO, MIRA
Entity Type:Individual
Prefix:
First Name:MIRA
Middle Name:
Last Name:YOO
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 1:2800 ELLIOTT AVE
Mailing Address - Street 2:APT 538
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-1170
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32015 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6001
Practice Address - Country:US
Practice Address - Phone:253-945-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA68608183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist