Provider Demographics
NPI:1881352490
Name:HENSTRA, ZANE TAYLER (CPHT)
Entity type:Individual
Prefix:
First Name:ZANE
Middle Name:TAYLER
Last Name:HENSTRA
Suffix:
Gender:M
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 KIDD AVE SE APT 35
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-2987
Mailing Address - Country:US
Mailing Address - Phone:435-619-4807
Mailing Address - Fax:
Practice Address - Street 1:3099 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-9836
Practice Address - Country:US
Practice Address - Phone:360-876-5212
Practice Address - Fax:360-876-7444
Is Sole Proprietor?:No
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61023216183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician