Basic Information
Provider Information
NPI: 1003000993
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCMANNIS
FirstName: STEPHEN
MiddleName: EDWARD
NamePrefix: MR.
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 312 N 45TH ST
Address2:  
City: SEATTLE
State: WA
PostalCode: 981036305
CountryCode: US
TelephoneNumber: 3307030373
FaxNumber:  
Practice Location
Address1: 117 SW 160TH STREET
Address2:  
City: BURIEN
State: WA
PostalCode: 98166
CountryCode: US
TelephoneNumber: 2062422030
FaxNumber: 2062422018
Other Information
ProviderEnumerationDate: 09/04/2007
LastUpdateDate: 12/11/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
183500000X03129498OHN Pharmacy Service ProvidersPharmacist 
183500000XPH60444168WAY Pharmacy Service ProvidersPharmacist 

No ID Information.


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