Provider Demographics
NPI:1124136551
Name:VIDAMO, JAMES MICHAEL
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:MICHAEL
Last Name:VIDAMO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12921 47TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208
Mailing Address - Country:US
Mailing Address - Phone:425-750-1596
Mailing Address - Fax:
Practice Address - Street 1:5006 132ND ST SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208
Practice Address - Country:US
Practice Address - Phone:425-357-6162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00021843183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician