1487696787 NPI number — CREDENA HEALTH LLC

Table of content: (NPI 1487696787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487696787 NPI number — CREDENA HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CREDENA HEALTH LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CREDENA HEALTH PHARMACY OLYMPIA
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487696787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2704
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-2704
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-493-7412
Provider Business Mailing Address Fax Number:
360-493-5403

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 LILLY RD NE
Provider Second Line Business Practice Location Address:
MAIL STOP LLH10
Provider Business Practice Location Address City Name:
OLYMPIA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98506-5133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-493-7412
Provider Business Practice Location Address Fax Number:
360-493-5403
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SKAFI
Authorized Official First Name:
MIKE
Authorized Official Middle Name:
Authorized Official Title or Position:
AVP/SECRETARY
Authorized Official Telephone Number:
575-650-3396

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHAR.CF.60658956 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2106972 . This is a "PK" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com