Provider Demographics
NPI:1699076356
Name:KIESSER, RUSTEL LEE (BPHARM, RPH)
Entity type:Individual
Prefix:MR
First Name:RUSTEL
Middle Name:LEE
Last Name:KIESSER
Suffix:
Gender:M
Credentials:BPHARM, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3506 NE 127TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-2829
Mailing Address - Country:US
Mailing Address - Phone:360-823-9951
Mailing Address - Fax:360-335-2008
Practice Address - Street 1:3307 EVERGREEN WAY STE 5
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2063
Practice Address - Country:US
Practice Address - Phone:360-335-2006
Practice Address - Fax:360-335-2008
Is Sole Proprietor?:No
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00017664183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist