Basic Information
| Provider Information | |||||||||
| NPI: | 1740718725 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOHL | ||||||||
| FirstName: | HAIDEN | ||||||||
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| Credential: | PHARMD. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 232 NE CEDAR AVE # B | ||||||||
| Address2: | |||||||||
| City: | COLLEGE PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993241161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062391052 | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 W POPLAR ST | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098973320 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2017 | ||||||||
| LastUpdateDate: | 06/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 183500000X | PHA-PHA-LIC-39576 | MT | N | Pharmacy Service Providers | Pharmacist | 183500000X | PH60672106 | WA | Y | Pharmacy Service Providers | Pharmacist |
No ID Information.