Provider Demographics
NPI:1922309046
Name:ENG, JERRY K
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:K
Last Name:ENG
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 1:17202 15TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5130
Mailing Address - Country:US
Mailing Address - Phone:206-364-4618
Mailing Address - Fax:206-367-9262
Practice Address - Street 1:17202 15TH AVE NE
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-5130
Practice Address - Country:US
Practice Address - Phone:206-364-4618
Practice Address - Fax:206-367-9262
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00009900183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist