Provider Demographics
NPI:1093123184
Name:PPGNW - ID PHARMACY
Entity Type:Organization
Organization Name:PPGNW - ID PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REVENUE CYCLE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WENDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-628-3826
Mailing Address - Street 1:2001 E MADISON ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-2959
Mailing Address - Country:US
Mailing Address - Phone:206-328-7734
Mailing Address - Fax:
Practice Address - Street 1:2001 E MADISON ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2959
Practice Address - Country:US
Practice Address - Phone:206-328-7734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-01
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID19941PDO332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site