Provider Demographics
NPI:1528317542
Name:KO, SANDRA MARIKO
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARIKO
Last Name:KO
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 1:16469 SE 57TH PL
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-5535
Mailing Address - Country:US
Mailing Address - Phone:425-746-3174
Mailing Address - Fax:
Practice Address - Street 1:1801 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5384
Practice Address - Country:US
Practice Address - Phone:425-313-9200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPH00015376183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist