Healthcare Provider Details

I. General information

NPI: 1114050333
Provider Name (Legal Business Name): JEFFREY GEBENUS RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 3RD AVE
SEATTLE WA
98104-1602
US

IV. Provider business mailing address

2721 1ST AVE UNIT 905
SEATTLE WA
98121-1143
US

V. Phone/Fax

Practice location:
  • Phone: 206-623-1190
  • Fax: 206-292-3957
Mailing address:
  • Phone: 206-915-8079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00042289
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: