Healthcare Provider Details

I. General information

NPI: 1497134373
Provider Name (Legal Business Name): MINA YACOUB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2015
Last Update Date: 08/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 13TH ST
EVERETT WA
98201-1689
US

IV. Provider business mailing address

16023 51ST PL W
EDMONDS WA
98026-4814
US

V. Phone/Fax

Practice location:
  • Phone: 425-404-4723
  • Fax:
Mailing address:
  • Phone: 425-345-8226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH60573062
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: