Healthcare Provider Details

I. General information

NPI: 1104951656
Provider Name (Legal Business Name): CHARLES MARK SAGEN RPH.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PIONEER EAST
MONTESANO WA
98563
US

IV. Provider business mailing address

31 RIMROCK LANE
MONTESANO WA
98563
US

V. Phone/Fax

Practice location:
  • Phone: 360-249-4444
  • Fax: 360-249-4595
Mailing address:
  • Phone: 360-249-4595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00010594
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: