Provider Demographics
NPI:1053445809
Name:GROUP HEALTH COOPERATIVE
Entity Type:Organization
Organization Name:GROUP HEALTH COOPERATIVE
Other - Org Name:REDMOND MEDICAL CENTER PHARMACY
Other - Org Type:Other Name
Authorized Official - Title/Position:PHARMACY MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:WESSELIUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-882-6152
Mailing Address - Street 1:12400 E MARGINAL WAY S
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-2559
Mailing Address - Country:US
Mailing Address - Phone:509-241-7198
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:15809 BEAR CREEK PARKWAY
Practice Address - Street 2:SUITE 110
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4370
Practice Address - Country:US
Practice Address - Phone:425-882-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GROUP HEALTH COOPERATIVE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACF60041218333600000X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA156111OtherL&I
WACF60041218OtherWA STATE BOARD OF PHARMACY LICENSE
WA4915762OtherNCPDP
WA4915762OtherNCPDP