1457414138 NPI number — WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES

Table of content: (NPI 1457414138)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457414138 NPI number — WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES
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:
1457414138
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 200
Provider Second Line Business Mailing Address:
S 2320 SALNAVE ROAD
Provider Business Mailing Address City Name:
MEDICAL LAKE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99022-0200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-299-1948
Provider Business Mailing Address Fax Number:
509-299-1967

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
S 2320 SALNAVE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MEDICAL LAKE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99022-0200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-299-1948
Provider Business Practice Location Address Fax Number:
509-299-1967
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BERG
Authorized Official First Name:
CARMEN
Authorized Official Middle Name:
JOY
Authorized Official Title or Position:
CLINICAL PHARMACIST SUPERVISOR
Authorized Official Telephone Number:
509-299-1948

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  PHAR.CF.00000468 , 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: 4904795 . This is a "NCPDP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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