Provider Demographics
NPI:1801315460
Name:MALACHI, MIKE
Entity type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MALACHI
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 1:12800 NE 4TH ST APT LL116
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-7007
Mailing Address - Country:US
Mailing Address - Phone:808-282-1477
Mailing Address - Fax:
Practice Address - Street 1:16300 SE EVELYN ST
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-9515
Practice Address - Country:US
Practice Address - Phone:503-656-1461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0016191183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORRPH-0016191Medicaid