Healthcare Provider Details

I. General information

NPI: 1730558685
Provider Name (Legal Business Name): KRISTOPHER HENDERSON PHARM. D., B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2015
Last Update Date: 07/21/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 BAY AVE
OCEAN PARK WA
98640-4203
US

IV. Provider business mailing address

101 BOLSTAD AVE
LONG BEACH WA
98631
US

V. Phone/Fax

Practice location:
  • Phone: 360-665-5181
  • Fax:
Mailing address:
  • Phone: 360-642-3200
  • Fax: 360-642-8786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH60603603
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberRPH-0014930
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: