Healthcare Provider Details

I. General information

NPI: 1083695324
Provider Name (Legal Business Name): PROVIDENCE HEALTH & SERVICES -WASHINGTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2005
Last Update Date: 05/15/2025
Certification Date: 05/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 E REZANOF DR
KODIAK AK
99615-6602
US

IV. Provider business mailing address

PO BOX 3706
PORTLAND OR
97208-3706
US

V. Phone/Fax

Practice location:
  • Phone: 907-486-9550
  • Fax: 907-486-9553
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336I0012X
TaxonomyInstitutional Pharmacy
License NumberPHAR355
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: DONALD WAYNE ANDERSON JR.
Title or Position: ASSISTANT SECRETARY OF ENROLLMENTS
Credential:
Phone: 425-358-9786