Healthcare Provider Details

I. General information

NPI: 1194703033
Provider Name (Legal Business Name): TERESITA MATEO PENNEY RX-TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 6TH AVE
TACOMA WA
98406-5405
US

IV. Provider business mailing address

1169 HUDSON ST
DUPONT WA
98327-8753
US

V. Phone/Fax

Practice location:
  • Phone: 253-761-1248
  • Fax: 253-761-7462
Mailing address:
  • Phone: 253-381-6212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA00044510
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: