Provider Demographics
NPI:1922488220
Name:EQUERE, MODUPEORE
Entity Type:Individual
Prefix:
First Name:MODUPEORE
Middle Name:
Last Name:EQUERE
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 1:4780 PARK DR
Mailing Address - Street 2:APT 104
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-6070
Mailing Address - Country:US
Mailing Address - Phone:425-319-9822
Mailing Address - Fax:
Practice Address - Street 1:540 N WEST AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1251
Practice Address - Country:US
Practice Address - Phone:360-435-5771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-02
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60511955183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist