Provider Demographics
NPI:1427475227
Name:IKEDA, IVY (PHARMD)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:
Last Name:IKEDA
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 THREE RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-3127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 THREE RIVERS DR
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-3127
Practice Address - Country:US
Practice Address - Phone:360-578-7387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORRPH-0013889183500000X
WAPH60583327183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist