Provider Demographics
NPI:1154989549
Name:CARMICHAEL, KATRINA RAE-PENINOY
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:RAE-PENINOY
Last Name:CARMICHAEL
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 1:11501 CANYON RD E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4359
Mailing Address - Country:US
Mailing Address - Phone:253-536-5296
Mailing Address - Fax:
Practice Address - Street 1:11501 CANYON RD E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4359
Practice Address - Country:US
Practice Address - Phone:253-536-5296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60864234183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist