Healthcare Provider Details

I. General information

NPI: 1497273528
Provider Name (Legal Business Name): MTM CLINICAL CARE RX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 SE EVERETT MALL WAY STE 210B
EVERETT WA
98208-3249
US

IV. Provider business mailing address

20531 76TH AVE SE
SNOHOMISH WA
98296-5166
US

V. Phone/Fax

Practice location:
  • Phone: 206-913-9664
  • Fax:
Mailing address:
  • Phone: 206-913-9664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number1477966612
License Number StateWA

VIII. Authorized Official

Name: JULIE V LE
Title or Position: MTM PHARMACIST
Credential: RPH
Phone: 206-913-9664