Provider Demographics
NPI:1538267950
Name:AVERETT, JUSTIN BASSETT (PHARMD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BASSETT
Last Name:AVERETT
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WAINWRIGHT DR (119)
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-3975
Mailing Address - Country:US
Mailing Address - Phone:509-525-5200
Mailing Address - Fax:
Practice Address - Street 1:77 WAINWRIGHT DR (119)
Practice Address - Street 2:
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-3975
Practice Address - Country:US
Practice Address - Phone:509-525-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP5929183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist