Healthcare Provider Details

I. General information

NPI: 1225657844
Provider Name (Legal Business Name): PAVEL MITIN PHARMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2020
Last Update Date: 04/14/2020
Certification Date: 04/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 KLA-OOK-WA DR
TAHOLAH WA
98587
US

IV. Provider business mailing address

15857 42ND AVE S
TUKWILA WA
98188-2653
US

V. Phone/Fax

Practice location:
  • Phone: 360-276-4405
  • Fax: 360-276-0188
Mailing address:
  • Phone: 206-707-3170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH60108956
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: