MEDICARE: JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3336S0011X	Specialty Pharmacy
2	3336C0003X	Community/Retail Pharmacy

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PHAR.CF.60884025	OTHER	WA	LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295218188
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JEFFERSON COUNTY PUBLIC HOSPITAL DISTRICT NO 2

Provider Business Mailing Address
First Line	:	PO BOX 104548
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91189-4548
Country	:	US
Telephone Number	:	360-385-2200
Fax Number	:

Provider Business Practice Location Address
First Line	:	9481 OAK BAY RD STE A
Second Line	:
City	:	PORT LUDLOW
State	:	WA
Zip	:	98365-9801
Country	:	US
Telephone Number	:	360-379-2254
Fax Number	:	360-379-2257

Authorized Official
Title or Position	:	CEO
Name	:	MIKE GLENN
Credential	:
Telephone Number	:	360-385-2200

Provider Enumeration Date	:	09/07/2018
Last Update Date	:	12/31/2025

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