Provider Demographics
NPI:1043214596
Name:VIRGINIA MASON MEDICAL CENTER
Entity Type:Organization
Organization Name:VIRGINIA MASON MEDICAL CENTER
Other - Org Name:ISSAQUAH PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD PHARMACIST
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:RPH PHARM D
Authorized Official - Phone:425-557-8003
Mailing Address - Street 1:100 NE GILMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-2925
Mailing Address - Country:US
Mailing Address - Phone:425-557-8003
Mailing Address - Fax:425-557-8021
Practice Address - Street 1:100 NE GILMAN BLVD
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2925
Practice Address - Country:US
Practice Address - Phone:425-557-8003
Practice Address - Fax:425-557-8021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA262010304679333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA4922806OtherNCPDP
WA6012926Medicaid