Provider Demographics
NPI:1356514145
Name:GATES, KIRK THOMAS
Entity type:Individual
Prefix:MR
First Name:KIRK
Middle Name:THOMAS
Last Name:GATES
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 1:12065 SW WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-3033
Mailing Address - Country:US
Mailing Address - Phone:360-790-2293
Mailing Address - Fax:
Practice Address - Street 1:12065 SW WALNUT ST
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-3033
Practice Address - Country:US
Practice Address - Phone:360-790-2293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORT-0011752183700000X
WAVA00057147183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician