Provider Demographics
NPI:1174053540
Name:PATEL, POONAM
Entity type:Individual
Prefix:
First Name:POONAM
Middle Name:
Last Name:PATEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20901 GLENBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-3810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19200 N KELSEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1431
Practice Address - Country:US
Practice Address - Phone:360-794-7994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2017-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60761981183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist