Healthcare Provider Details

I. General information

NPI: 1235117482
Provider Name (Legal Business Name): TRENT PERSHALL RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 STATE ROUTE 9 NE
LAKE STEVENS WA
98258-8525
US

IV. Provider business mailing address

621 SR 9
LAKE STEVENS WA
98258-8525
US

V. Phone/Fax

Practice location:
  • Phone: 425-334-4028
  • Fax:
Mailing address:
  • Phone: 425-334-4028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00040593
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: