Provider Demographics
NPI:1932511185
Name:PERILLO, THEODORE (RPH)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:PERILLO
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 1:15924 223RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:WOODINVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98077-7486
Mailing Address - Country:US
Mailing Address - Phone:217-512-1917
Mailing Address - Fax:
Practice Address - Street 1:15924 223RD AVE NE
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98077-7486
Practice Address - Country:US
Practice Address - Phone:217-512-1917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60327482183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA554048OtherNABP