=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912073388
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEATTLE-KING COUNTY DEPT OF PUBLIC HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 10/13/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 620 W JAMES ST KCCF RJC PHARMACY
-----------------------------------------------------
City | KENT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98032-4487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-205-2400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 YESLER WAY SUITE 300
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98104-2628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-205-5975
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGEMENT ADMINISTRATOR
-----------------------------------------------------
Name | KEVIN ARDELL MOE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 206-263-8807
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3336C0002X
-----------------------------------------------------
Taxonomy Name | Clinic Pharmacy
-----------------------------------------------------
License Number | FO00055849
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------