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General NPI Number Information
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NPI Number | 1083695324
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Entity Type | Organization
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Legal Business Name | PROVIDENCE HEALTH & SERVICES -WASHINGTON
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Dates
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Enumeration Date | 11/11/2005
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | 1915 E REZANOF DR
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City | KODIAK
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State | AK
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Zip | 99615-6602
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Country | US
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Telephone | 907-486-9550
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Fax | 907-486-9553
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Provider Business Mailing Address
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Address Line | PO BOX 3706
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City | PORTLAND
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State | OR
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Zip | 97208-3706
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | ASSISTANT SECRETARY OF ENROLLMENTS
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Name | DONALD WAYNE ANDERSON JR.
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Credential |
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Telephone | 425-358-9786
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336I0012X
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Taxonomy Name | Institutional Pharmacy
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License Number | PHAR355
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License Number State | AK
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