Provider Demographics
NPI:1922608439
Name:PERVINICH, BLAINE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:BLAINE
Middle Name:
Last Name:PERVINICH
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3695 SE SOHOLT LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-7899
Mailing Address - Country:US
Mailing Address - Phone:360-471-0199
Mailing Address - Fax:
Practice Address - Street 1:1610 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2408
Practice Address - Country:US
Practice Address - Phone:360-471-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61076550183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist