1396937769 NPI number — KALISPEL INDIAN COMMUNITY OF THE KALISPEL RESERVATION WASHINGTON

Table of content: AMY MARIE MOLL PHARMD, CCP (NPI 1871874230)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396937769 NPI number — KALISPEL INDIAN COMMUNITY OF THE KALISPEL RESERVATION WASHINGTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KALISPEL INDIAN COMMUNITY OF THE KALISPEL RESERVATION WASHINGTON
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:
Provider Other Organization Name Type Code:
6
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:
1396937769
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 67
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CUSICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99119-0067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-447-7111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1821 LECLERC RD N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CUSICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99119-9682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-447-7111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KERSTING
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF MEDICAL SERVICES
Authorized Official Telephone Number:
509-447-7111

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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