Provider Demographics
NPI:1932438975
Name:MICKEY, ROBERTA AUDRINE (RPH)
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:AUDRINE
Last Name:MICKEY
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SEQUIM
Mailing Address - State:WA
Mailing Address - Zip Code:98382-3342
Mailing Address - Country:US
Mailing Address - Phone:360-681-2018
Mailing Address - Fax:360-681-7059
Practice Address - Street 1:490 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SEQUIM
Practice Address - State:WA
Practice Address - Zip Code:98382-3342
Practice Address - Country:US
Practice Address - Phone:360-681-2018
Practice Address - Fax:360-681-7059
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00048789183500000X
NMRP00004871183500000X
CARPH40163183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist