Provider Demographics
NPI:1063699296
Name:DESTAN, ANAYA THETA (RPH)
Entity type:Individual
Prefix:
First Name:ANAYA
Middle Name:THETA
Last Name:DESTAN
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:ESTRELLITA
Other - Middle Name:
Other - Last Name:CHUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMACIST
Mailing Address - Street 1:2226 EASTLAKE AVE E # 282
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3419
Mailing Address - Country:US
Mailing Address - Phone:206-451-7416
Mailing Address - Fax:
Practice Address - Street 1:2226 EASTLAKE AVE E #282
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3419
Practice Address - Country:US
Practice Address - Phone:206-451-7416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00017294183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist