Provider Demographics
NPI:1144224692
Name:VIRGINIA MASON SOUTH CLINIC PHARMACY
Entity Type:Organization
Organization Name:VIRGINIA MASON SOUTH CLINIC PHARMACY
Other - Org Name:VIRGINIA MASON FEDERAL WAY PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUONG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:206-583-6011
Mailing Address - Street 1:33501 1ST WAY S
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6208
Mailing Address - Country:US
Mailing Address - Phone:253-874-1650
Mailing Address - Fax:253-874-1665
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:253-874-1650
Practice Address - Fax:253-874-1665
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VIRGINIA MASON BUCK PAVILION PHARMACY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-10
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
WACF000031383336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6015978Medicaid
2108464OtherPK