Provider Demographics
NPI:1427467075
Name:WICHTERMAN, TARA MICHELLE
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELLE
Last Name:WICHTERMAN
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 1:916 W EVERGREEN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3035
Mailing Address - Country:US
Mailing Address - Phone:360-213-2236
Mailing Address - Fax:360-213-2238
Practice Address - Street 1:1804 COLUMBIA BLVD
Practice Address - Street 2:
Practice Address - City:SAINT HELENS
Practice Address - State:OR
Practice Address - Zip Code:97051-1733
Practice Address - Country:US
Practice Address - Phone:503-397-5555
Practice Address - Fax:503-397-5441
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0014232183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RPH-0014232OtherRPH LICENSE