Healthcare Provider Details

I. General information

NPI: 1972608792
Provider Name (Legal Business Name): DWIGHT ALDEN WAHLBORG RPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSHCS 9600 VETERAN S DR ATTN; (119)
TACOMA WA
98493-0001
US

IV. Provider business mailing address

4747 45TH AVE SW
SEATTLE WA
98116-4403
US

V. Phone/Fax

Practice location:
  • Phone: 253-583-2349
  • Fax: 253-589-4062
Mailing address:
  • Phone: 206-937-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P1200X
TaxonomyPharmacotherapy Pharmacist
License NumberPH00011230
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: