Provider Demographics
NPI:1215449483
Name:PAK, JAE B (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JAE
Middle Name:B
Last Name:PAK
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4818 POINT FOSDICK DR NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-1711
Mailing Address - Country:US
Mailing Address - Phone:253-851-3175
Mailing Address - Fax:253-851-6953
Practice Address - Street 1:3838 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4416
Practice Address - Country:US
Practice Address - Phone:253-564-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-28
Last Update Date:2017-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH60758209183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist