Provider Demographics
NPI:1386160687
Name:SAN BUENAVENTURA, JOANNALYN (PHARMACY TECHNICIAN)
Entity type:Individual
Prefix:MRS
First Name:JOANNALYN
Middle Name:
Last Name:SAN BUENAVENTURA
Suffix:
Gender:F
Credentials:PHARMACY TECHNICIAN
Other - Prefix:MS
Other - First Name:JOANNALYN
Other - Middle Name:
Other - Last Name:RAMELB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2737 DIAMOND ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-8348
Mailing Address - Country:US
Mailing Address - Phone:253-347-9091
Mailing Address - Fax:
Practice Address - Street 1:1200 SW 27TH ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-2603
Practice Address - Country:US
Practice Address - Phone:206-630-7910
Practice Address - Fax:877-224-4167
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA00066211183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVA00066211OtherWA PHARMACY TECHNICIAN LICENSE
360101060763490OtherPTCB LICENSE