Provider Demographics
NPI:1760752299
Name:SKOMORUCHA, MICHELE
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:
Last Name:SKOMORUCHA
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 1:3632 KANSAS ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-6060
Mailing Address - Country:US
Mailing Address - Phone:206-427-9807
Mailing Address - Fax:
Practice Address - Street 1:1070 E SUNSET DR
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-3509
Practice Address - Country:US
Practice Address - Phone:360-647-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA40934183500000X
DEA1-0002918183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist