Basic Information
| Provider Information | |||||||||
| NPI: | 1669877601 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUHAT | ||||||||
| FirstName: | MERIVIC | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHARMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 85TH DR SE | ||||||||
| Address2: | |||||||||
| City: | LAKE STEVENS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982587377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893364 | ||||||||
| FaxNumber: | 4257893365 | ||||||||
| Practice Location | |||||||||
| Address1: | 1605 SE EVERETT MALL WAY | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982082838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4257893364 | ||||||||
| FaxNumber: | 4257893365 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 11/04/2014 | ||||||||
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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 | PH00040674 | WA | Y | Pharmacy Service Providers | Pharmacist |
ID Information
| ID | Type | State | Issuer | Description | PH00040674 | 01 | WA | WASHINGTON STATE PHARMACIST LICENSE | OTHER |