Provider Demographics
NPI:1750644399
Name:MASSINGHAM, PETER GERARD
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GERARD
Last Name:MASSINGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E LAURIDSEN BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-7851
Mailing Address - Country:US
Mailing Address - Phone:360-452-4410
Mailing Address - Fax:360-452-0951
Practice Address - Street 1:114 E LAURIDSEN BLVD
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-7851
Practice Address - Country:US
Practice Address - Phone:360-452-4410
Practice Address - Fax:360-452-0951
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00043180183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist