Provider Demographics
NPI:1871883306
Name:BAKEN, JOHN TYLER
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:TYLER
Last Name:BAKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:BAKEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:R PH
Mailing Address - Street 1:12 N 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3065
Mailing Address - Country:US
Mailing Address - Phone:509-966-4865
Mailing Address - Fax:509-452-0342
Practice Address - Street 1:12 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3065
Practice Address - Country:US
Practice Address - Phone:509-966-4865
Practice Address - Fax:509-452-0342
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH 9879183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist