Provider Demographics
NPI:1669925996
Name:MOMBERG, CELESTE D (B PHARM)
Entity type:Individual
Prefix:
First Name:CELESTE
Middle Name:D
Last Name:MOMBERG
Suffix:
Gender:F
Credentials:B PHARM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 BROADWAY E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5009
Mailing Address - Country:US
Mailing Address - Phone:206-323-6586
Mailing Address - Fax:206-328-6960
Practice Address - Street 1:417 BROADWAY E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-5009
Practice Address - Country:US
Practice Address - Phone:206-323-6586
Practice Address - Fax:206-328-6960
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-03
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00054331183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist