Healthcare Provider Details

I. General information

NPI: 1740355320
Provider Name (Legal Business Name): WASHINGTON STATE DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2120 RYAN RD
BUCKLEY WA
98321-9115
US

IV. Provider business mailing address

2120 RYAN RD
BUCKLEY WA
98321-9115
US

V. Phone/Fax

Practice location:
  • Phone: 360-829-3415
  • Fax: 360-829-3076
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License NumberFL00000713
License Number StateWA

VIII. Authorized Official

Name: GUY KUESTERMEYER
Title or Position: PHARMACY DIRECTOR
Credential: PHARM D
Phone: 360-829-3415