Healthcare Provider Details

I. General information

NPI: 1770567646
Provider Name (Legal Business Name): MASOUD EDALATIE R.PH.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 1ST AVE N
SEATTLE WA
98109-4001
US

IV. Provider business mailing address

14614 78TH AVE NE
KENMORE WA
98028-4628
US

V. Phone/Fax

Practice location:
  • Phone: 206-284-1354
  • Fax: 206-378-6060
Mailing address:
  • Phone: 425-402-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPH00019260
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: