Provider Demographics
NPI:1932402260
Name:BALDERRAMA, JORGE FABIAN (PHARMD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:FABIAN
Last Name:BALDERRAMA
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 BROADWAY E APT 226
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-5373
Mailing Address - Country:US
Mailing Address - Phone:915-920-3982
Mailing Address - Fax:
Practice Address - Street 1:1410 E JOHN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5218
Practice Address - Country:US
Practice Address - Phone:206-323-4935
Practice Address - Fax:206-323-6029
Is Sole Proprietor?:No
Enumeration Date:2010-12-08
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60159486183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist