Healthcare Provider Details

I. General information

NPI: 1528630563
Provider Name (Legal Business Name): ADRIEL SUPNET PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2021
Last Update Date: 07/10/2021
Certification Date: 07/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 ROOSEVELT WAY NE
SEATTLE WA
98125-6234
US

IV. Provider business mailing address

PO BOX 22445
SEATTLE WA
98122-0445
US

V. Phone/Fax

Practice location:
  • Phone: 206-890-0150
  • Fax:
Mailing address:
  • Phone: 206-890-0150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH61189304
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: