Provider Demographics
NPI:1427693258
Name:PHELPS, MAX DWIGHT (PH00009411)
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:DWIGHT
Last Name:PHELPS
Suffix:
Gender:M
Credentials:PH00009411
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23234 114TH WAY SE
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98031-3429
Mailing Address - Country:US
Mailing Address - Phone:206-683-1035
Mailing Address - Fax:
Practice Address - Street 1:25316 74TH AVE S STE 105
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-6022
Practice Address - Country:US
Practice Address - Phone:800-562-8386
Practice Address - Fax:800-421-7772
Is Sole Proprietor?:No
Enumeration Date:2019-11-15
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH000094111835G0303X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835G0303XPharmacy Service ProvidersPharmacistGeriatric