Provider Demographics
NPI:1679290480
Name:SIU, MELADINE E
Entity type:Individual
Prefix:
First Name:MELADINE
Middle Name:E
Last Name:SIU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14915 72ND PL NE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-4916
Mailing Address - Country:US
Mailing Address - Phone:206-295-2708
Mailing Address - Fax:
Practice Address - Street 1:22803 44TH AVE W STE B
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-5032
Practice Address - Country:US
Practice Address - Phone:425-771-3738
Practice Address - Fax:425-776-1190
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-21
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60780008183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician