Provider Demographics
NPI:1669804449
Name:YI, TAE (RPH)
Entity type:Individual
Prefix:
First Name:TAE
Middle Name:
Last Name:YI
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 1:930 NE HIGH ST
Mailing Address - Street 2:322
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98029-7417
Mailing Address - Country:US
Mailing Address - Phone:702-612-8779
Mailing Address - Fax:
Practice Address - Street 1:2411 N PROCTOR ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5335
Practice Address - Country:US
Practice Address - Phone:253-759-9889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00040013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist