MEDICARE: MR. RAYMUNDO SIRVELON DEGALA FELICITAS JR. PHARMACY TECHNICIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	183700000X	Pharmacy Technician	VA00055516	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VA00055516	OTHER	WA	PHARMACY TECHNICIAN

General Provider Information

NPI Number	:	1326022682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAYMUNDO SIRVELON DEGALA FELICITAS JR. PHARMACY TECHNICIAN

Provider Business Mailing Address
First Line	:	5031 MARTIN LUTHER KING JR WAY S
Second Line	:	# 18
City	:	SEATTLE
State	:	WA
Zip	:	98118-1963
Country	:	US
Telephone Number	:	206-721-9129
Fax Number	:

Provider Business Practice Location Address
First Line	:	5031 MARTIN LUTHER KING JR WAY S
Second Line	:	# 18
City	:	SEATTLE
State	:	WA
Zip	:	98118-1963
Country	:	US
Telephone Number	:	206-721-9129
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2005
Last Update Date	:	07/08/2007

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