MEDICARE: WESTERN PHARMACY GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies
2	3336C0003X	Community/Retail Pharmacy	55905	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2176005	OTHER		PK

General Provider Information

NPI Number	:	1750399739
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN PHARMACY GROUP LLC

Provider Business Mailing Address
First Line	:	851 COHO WAY STE 312
Second Line	:
City	:	BELLINGHAM
State	:	WA
Zip	:	98225-2066
Country	:	US
Telephone Number	:	360-685-4263
Fax Number	:

Provider Business Practice Location Address
First Line	:	286 EUCLID AVE STE 206
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92114-3612
Country	:	US
Telephone Number	:	619-819-2200
Fax Number	:	619-819-2212

Authorized Official
Title or Position	:	CEO
Name	:	KEVIN FARIS
Credential	:
Telephone Number	:	360-220-4818

Provider Enumeration Date	:	08/04/2006
Last Update Date	:	07/19/2018

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