MEDICARE: WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES

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	3336L0003X	Long Term Care Pharmacy	PHAR.CF.00000468	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4904795	OTHER	WA	NCPDP

General Provider Information

NPI Number	:	1457414138
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 200
Second Line	:	S 2320 SALNAVE ROAD
City	:	MEDICAL LAKE
State	:	WA
Zip	:	99022-0200
Country	:	US
Telephone Number	:	509-299-1948
Fax Number	:	509-299-1967

Provider Business Practice Location Address
First Line	:	S 2320 SALNAVE ROAD
Second Line	:
City	:	MEDICAL LAKE
State	:	WA
Zip	:	99022-0200
Country	:	US
Telephone Number	:	509-299-1948
Fax Number	:	509-299-1967

Authorized Official
Title or Position	:	CLINICAL PHARMACIST SUPERVISOR
Name	:	CARMEN JOY BERG
Credential	:	RPH
Telephone Number	:	509-299-1948

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	03/07/2023

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Directions to “WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES ” Practice Location

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