Healthcare Provider Details

I. General information

NPI: 1427693258
Provider Name (Legal Business Name): MAX DWIGHT PHELPS PH00009411
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2019
Last Update Date: 11/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25316 74TH AVE S STE 105
KENT WA
98032-6022
US

IV. Provider business mailing address

23234 114TH WAY SE
KENT WA
98031-3429
US

V. Phone/Fax

Practice location:
  • Phone: 800-562-8386
  • Fax: 800-421-7772
Mailing address:
  • Phone: 206-683-1035
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835G0303X
TaxonomyGeriatric Pharmacist
License NumberPH00009411
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: