Basic Information
| Provider Information | |||||||||
| NPI: | 1306216122 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYNES | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DOCTOR OF PHARMACY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 108 N APPLE BLOSSOM DR | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988168679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096824634 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 108 N APPLE BLOSSOM DR | ||||||||
| Address2: | |||||||||
| City: | CHELAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988168679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096824634 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2015 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | 3580 | NH | N | Pharmacy Service Providers | Pharmacist | 183500000X | PH60542865 | WA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.