Provider Demographics
NPI:1083695324
Name:PROVIDENCE HEALTH SYSTEM-WASHINGTON
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH SYSTEM-WASHINGTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIR REIMB ADMIN & ASST SEC FOR ENRO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:1915 E REZANOF DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6602
Mailing Address - Country:US
Mailing Address - Phone:907-486-9550
Mailing Address - Fax:907-486-9553
Practice Address - Street 1:1915 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6602
Practice Address - Country:US
Practice Address - Phone:907-486-9550
Practice Address - Fax:907-486-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-11
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKPHAR3553336I0012X
3336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336I0012XSuppliersPharmacyInstitutional Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1997047OtherPK