1427105030 NPI number — WASHINGTON STATE UNIVERSITY

Table of content: (NPI 1427105030)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427105030 NPI number — WASHINGTON STATE UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON STATE UNIVERSITY
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:
1427105030
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 642302
Provider Second Line Business Mailing Address:
1125 SE WASHINGTON STREET
Provider Business Mailing Address City Name:
PULLMAN
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99164-2302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-335-5742
Provider Business Mailing Address Fax Number:
509-335-5745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1125 SE WASHINGTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PULLMAN
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99163
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-335-5742
Provider Business Practice Location Address Fax Number:
509-335-5745
Provider Enumeration Date:
01/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HEDENSTROM
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PHARMACY MANAGER
Authorized Official Telephone Number:
509-335-5742

Provider Taxonomy Codes

  • Taxonomy code: 3336C0002X , with the licence number:  CF0056228 , 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: 4926537 . This is a "NABP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 6012942 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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