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General NPI Number Information
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NPI Number | 1457414138
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Entity Type | Organization
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Legal Business Name | WASHINGTON STATE DEPT OF SOCIAL AND HEALTH SERVICES
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Dates
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Enumeration Date | 12/18/2006
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | S 2320 SALNAVE ROAD
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City | MEDICAL LAKE
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State | WA
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Zip | 99022-0200
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Country | US
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Telephone | 509-299-1948
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Fax | 509-299-1967
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Provider Business Mailing Address
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Address Line | PO BOX 200 S 2320 SALNAVE ROAD
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City | MEDICAL LAKE
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State | WA
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Zip | 99022-0200
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Country | US
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Telephone | 509-299-1948
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Fax | 509-299-1967
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Authorized Official
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Title or Position | CLINICAL PHARMACIST SUPERVISOR
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Name | CARMEN JOY BERG
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Credential | RPH
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Telephone | 509-299-1948
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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 | PHAR.CF.00000468
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License Number State | WA
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