Healthcare Provider Details

I. General information

NPI: 1821030123
Provider Name (Legal Business Name): WASHINGTON STATE DEPT. OF SOCIAL & HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 SPEYERS RD
SELAH WA
98942-1050
US

IV. Provider business mailing address

609 SPEYERS RD
SELAH WA
98942-1050
US

V. Phone/Fax

Practice location:
  • Phone: 509-698-1345
  • Fax: 509-697-2217
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License NumberFL00001190
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID L. CHRISTENSEN
Title or Position: PHARMACIST
Credential: RPH
Phone: 509-698-1345