Healthcare Provider Details

I. General information

NPI: 1912956848
Provider Name (Legal Business Name): ELIZABETH ANN BAKKEN PHARMACIST
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 S GRAND AVE
PULLMAN WA
99163-4900
US

IV. Provider business mailing address

845 SE HIGH ST
PULLMAN WA
99163-2265
US

V. Phone/Fax

Practice location:
  • Phone: 509-332-0602
  • Fax:
Mailing address:
  • Phone: 509-332-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00013586
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberP5716
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: