Provider Demographics
NPI:1891765772
Name:BAXLEY, BERRY DALE (RPH)
Entity Type:Individual
Prefix:MR
First Name:BERRY
Middle Name:DALE
Last Name:BAXLEY
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3714 SW 108TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98146-1754
Mailing Address - Country:US
Mailing Address - Phone:206-241-5141
Mailing Address - Fax:
Practice Address - Street 1:31515 20TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-5458
Practice Address - Country:US
Practice Address - Phone:253-839-9322
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00020799183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist